PHYSICIAN'S LETTER REGARDING INDEPENDENT LIVING
Court Administrator Probate Division
Re:
The Conservatorship of _______________ Court File No: ______________________
Dear Sir or Madam:
I, __________________________, the undersigned physician, state that I am the attending physician of the above-named conservatee; that I have been the protected person's physician since ______________, and that I examined the above-named protected person on ________________________________________________________________. I believe that ____________________ is no longer able to live independently due to her/his diagnosis of __________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ and as evidenced by the following behavior: __________________________________________________________________________ __________________________________________________________________________ Dated:__________________________ ______________________________________ Signature of Attending Physician Address:_______________________________ ______________________________________ ______________________________________ Telephone No: __________________________
GAC 21-UL
State
ENG
Rev 9/03-D
www.courts.state.mn.us/forms
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