Sample Physician Referral Letter Template printable pdf download

Sample Physician Referral Letter Template

Sample of a Physician Referral Letter

[Date]

Re: [Patient’s Name] Letter of Medical Necessity

Dear Dr. [Bariatric Surgeon’s Name],

I am referring [patient’s name] for evaluation and consideration for a weight

management surgical procedure. (S)He currently weighs [# of lbs] pounds and is

[# of in.] inches tall. Her/His BMI is [BMI #].

I have been [patient’s name]’s primary care physician for the past [#of yrs] years.

I have supervised several of her/his weight control diets and programs. None of these

have resulted in any sustained weight loss. As a result of this persistent morbid obesity,

her/his co-morbid conditions are becoming more difficult to manage. These co-morbid

conditions are as follows:

Duration:

Medication:

1. Hypertension

3 years

Norvasc/Tenormin

2. Diabetes Mellitus

5 years

Glucophage

3. Obesity Related Depression

3 years

Prozac

Losing weight will certainly make these conditions easier to manage. Since non-surgical

programs have failed to provide any long-term benefits for the patient, I feel surgery is

her/his only option.

I hope you will find [patient’s name] a suitable candidate for the surgical weight

reduction program. It will provide a tool to assist her/him in losing weight, as well as

maintain that weight loss. I anticipate that this will provide her/him with a significantly

improved quality of life.

Sincerely,

[Physician signature]

Dr. [Physician’s Name]

Sample Physician Referral Letter Template