Healthcare Provider Verification Form for Post-Lost expenses

For personal, family reasons, we will not be reviewing applications at this time. We will still accept applications and verifications and hope to review starting the weekend of October 6.

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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Free Guide for Families in Crisis

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