To Whom It May Concern:
My child____________________________________ was receiving services from
________________________________ for his/her therapy needs. He/She is not receiving therapy services from anyone else at this time. Therefore, I am requesting my child receive services from your facility.
____________________________________ ___________________
Name of Child Date of Birth
Address: ________________________ Medicaid# ______________________
________________________________ Last Date of Service: _____________Phone#: ________________________
Signature of Parent/Guardian _______________________________________Date: __________________________