Letter Request Form
ALL LETTERS MUST BE PICKED UP IN PERSON.
$10 LETTER FEE - DUE AT PICK UP OF FORM.
PLEASE BRING: 2 PROOF OF ADDRESS, GOVERNMENT ISSUED ID (Drivers License/ State ID/ Passport, BIRTH CERTIFICATE FOR EACH CHILD.) IF GUARDIAN - PROOF OF LEGAL APPOINTMENT.
GIVE 3 TO 5 BUSINESS DAYS TO PROCESS REQUEST.
Enter the Date of Request
Letter Regarding: Patient's Name and Date of Birth, if more than one list all children.
Name of Person Requesting Letter and DOB
Eg. IRS, Con Ed, School,etc...
