Back to template

HTML Preview MCF Physician Letter Confirm Dx page number 1.


Physician Letter Certification of Diagnosis
Letterhead
Physician’s Full Name
Address
Specialty
Medical License Number
Date
Dear Maryland Cancer Fund Coordinator:
This letter is to certify that ________________________________ has been
Patient Name
□ diagnosed with _______________________________, on ___________________or
Type of Cancer Date of Diagnosis
□
is being treated for ____________________________, and began treatment on
Type of Cancer
___________________, or
Date Treatment began
□ has finding suggestive of ____________________ and needs to obtain a cancer diagnosis.
Type of Cancer
Sincerely,
Physician’s Signature
DOWNLOAD HERE


Speak the truth, but leave immediately after. | Unknown