LETTER OF SUPPORT - Lloyd F Moss Free Clinic - lloydfmossfreeclinic 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. Ensure you format it correctly as MM/DD/YYYY.
3. In the section for Patient’s SSN, input the patient’s Social Security Number in the designated format.
4. Next, fill in your name as the supporter in the provided space. This identifies you as the individual providing support.
5. Enter the patient's name in the corresponding field to specify who you are supporting.
6. Check all applicable services you provide, such as food, housing, financial support, or transportation. If 'Other' is selected, specify what additional support you offer.
7. Complete your personal information below, including your address and phone number. This is essential for verification purposes.
8. Indicate your relationship to the patient clearly and sign at the bottom of the form to validate your support.

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