Physician’s Letterhead Here


To Whom It May Concern:

Jane Doe (DOB 00/00/00) has been a patient under the care of this medical practice since 19**. Medical records indicate that when she signed her Power of Attorney, she had mental capacity to do so.

Ms. Doe was diagnosed in (month, year) with cognitive impairment. It is the professional opinion of this medical practice that she no longer has capacity to make independent legal, medical, and financial decisions. This condition is not expected to improve.

Feel free to contact me at (000) 123-4567 if you require further information.


John Brown, MD                    (Date)

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