Letter of Support

Letter of Support

Your name has been given to the PIEDMONT REGIONAL DENTAL CLINIC concerning the support you are providing for a patient. For us to determine eligibility for our Affordable Care Program, the person providing support must complete the following information.
SUPPORTER : Full Name*
Relationship to Patient*
Email Address
Primary Phone
PATIENT : Full Name*
I provide the patient with Type of Assistance – i.e. rent/housing, food, utilities, etc.* as of Month/Year * .
I am in no way responsible for their medical bills or other health-related costs.
SIGNATURE OF SUPPORTER*

Clear
SUBMISSION DATE

MonthDayYear
Date
Should be Empty: