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 michelle@colettelouise.com.

Foundation Verification Letter for Loss
Your Name*
Hospital Address*
MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 100 MB.
I agree that by marking yes, I am attesting that the information in this application is correct to the best of my knowledge.*

Free Guide for Families in Crisis

Join our newsletter and you’ll receive this free guide, along with continued support and resources from The Colette Louise Tisdahl Foundation.

Name*