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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
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