Sample Doctor’s Form to Verify Medical Expenses for Housing

Basic form confirming medical information. If you Housing Authority does not have a doctor’s form or gives you a different type of form that does not leave adequate space, you can write “see attached” and attach a form like this:


Name of Patient: ______________________________

Please list below any prescribed medications that are currently medically necessary and anticipated to continue to be necessary in the upcoming year:

Please list below any services or treatments that are currently medically necessary and anticipated to continue to be necessary in the upcoming year:

  • Type of Service or treatment visit: Frequency needed (weekly, monthly, etc):

Please list below any medical equipment, apparatus, or other items that are medically necessary to purchase in the upcoming year:

Please list below any nutritional supplements, vitamins, herbal supplements, and natural medicines that are recommended by a medical practitioner as treatment for a specific medical condition diagnosed by a physician. Please list items that are currently medically necessary and anticipated to continue to be necessary in the upcoming year:

Name and Title of Medical Practitioner: _____________________________

Firm/Organization: ________________________________________

Signature: ________________________________________

Date: ________________________________________


Sample Letter

Some housing programs will reject expenses if it they determine that they are not ongoing/anticipated expenses in the upcoming year. The form above states that all expenses are anticipated. If helpful, you can also request a short statement of verification from your doctor. For Example:

Ms. R is disabled and is under my medical care.

Due to the ongoing nature of her disability, she will continue to require medical care in the upcoming year. The above treatments and medical expenses are all anticipated to continue throughout the upcoming year. In addition, her current visits with medical practitioners are anticipated to continue throughout the upcoming year.

Please see attached documentation of current medical expenses, which are all anticipated to continue at a similar rate.

Sincerely,

Dr. x