Cover The Caregiver
Caregiver Relief Grant — Medical Attestation
This form confirms only that the named patient has an active diagnosis of amyotrophic lateral sclerosis (ALS). No clinical detail, history, or documentation beyond this page is requested or required.
Patient name
Date of diagnosis
Primary family caregiver
I attest that I am the treating physician or neurologist for the patient named above, and that the patient currently has an active diagnosis of amyotrophic lateral sclerosis (ALS).
Clinician name & credentials
Practice / institution
State license number (optional)
Contact phone or email
Signature
Date