SAMPLE LETTER OF MEDICAL NECESSITY FOR BARIATRIC SURGERY
from the Fake Office of Dr. Sample McSampleton (REFERENCE ONLY)
Dr. Dang Tuan Pham and Dr. John D. Rutkoski
2625 Harlem Rd, Suite 160
Buffalo, New York 14225
RE: ___________________ (Patient Name)
Dear Drs. Pham & Rutkoski,
I am referring my patient ___________________________ to you for consideration of weight loss surgery for
severe obesity. The patient has been struggling with obesity for greater than 5 years. His/Her attempts at weight
loss while under my supervision have not yield long-term success despite numerous counseling attempts at
his/her office visits.
The patient’s history includes co-morbidities of _________________________________
_______________________________ (i.e. CAD, HTN, DM, hyperlipidemia, sleep apnea, obesity related
hyperventilation.) There is no significant liver kidney, or gastrointestinal disease present; there is no treatable
metabolic cause for obesity such as adrenal or thyroid disorder. TSH levels are normal upon testing. Current
medications are as follows:
There is no history of ongoing alcohol or drug abuse.
The patient weighs _______ pounds and measures _______ in height. The patient is clear to proceed with
bariatric surgery from a cardiac and/or pulmonary standpoint. The remainder of the physical exam is
I believe the patient is a good candidate for surgery and would benefit from significant weight loss. I would be
happy to see the patient again prior to surgery for medical clearance.
THIS IS A SAMPLE LETTER FOR YOUR REFERENCE ONLY. THE LETTER IS SUBMITTED
TO THE PATIENT’S INSURANCE COMPANY MUST NOT JUST BE THIS FORM WITH THE
BLANKS FILLED IN, EVEN IF YOUR DOCTOR’S NAME REALLY IS DR. SAMPLE
MCSAMPLETON. YOU MAY WANT TO SAVE YOUR OWN TEMPLATE FOR FUTURE USE.
2625 Harlem Road, Suite 160, Buffalo, New York 14225
Tel: (716) 893-0333 / Fax: (716) 893-3038