Healthcare Provider Verification Form for Post-Loss Expenses

Provider Verification Form for Post Loss Expenses

This form is provided to serve as the verification piece of loss expenses.  It is to be completed by the patient's doctor, social worker, or nurse, or other healthcare provider with knowledge of the loss.  We do not require this form, but do require some type of verification from one of these entities.  You can upload your verification at the bottom of the page, email the verification to michelle@colettelouise.com, or have the provider fill out and submit the form online. 

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If it is easier, you can also download the attached template of a letter and use for verification.

Foundation Verification Letter for Loss