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DATE NAME OF PROFESSIONAL (therapist, physician, psychiatrist, rehabilitation counselor) ADDRESS PHONE Dear Cheyenne Property Management Group, LLC, is my patient, and has been under my care since
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The name of the professional formrapist is Dr. Smith.
The healthcare facility where the professional formrapist is employed is required to file the form.
The form must be filled out with the full name and contact information of the professional formrapist.
The purpose of the form is to provide accurate information about the professional formrapist for record-keeping purposes.
The information that must be reported includes the name, contact information, and professional credentials of the formrapist.
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