Healthcare Provider Verification Form for Post-Lost expenses

Healthcare providers: Please fill out the form below or use the template as a letter and email to

Foundation Verification Letter for Loss

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Your Name*
Hospital Address*
MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 50 MB.
I agree that by marking yes, I am attesting that the information in this application is correct to the best of my knowledge.*
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