PCP Letter Template

[imreadynow 18]

I'm posting this because I had trouble finding it on this site and saw that several other people were looking for something similar too. This has to be on your PCP's letterhead. Bring this with you to your appointment with your PCP for medical clearance (I even filled mine out myself!)

[Date]

Re: [patient’s name]

Date of Birth:

To whom it may concern:

[Patient’s name] has been a patient of mine for [insert number] years. Patient is [insert height] tall and

weighs [insert weight] pounds for a calculated BMI of [insert number]. This patient has been excessively

overweight for the last [insert number of years] and will benefit from Bariatric surgery.

The patient is medically cleared for surgery. An EKG [also insert names of other tests included such as

laboratory tests, stress test, echocardiogram, sleep study and/or PFT] is provided with this letter.

In addition to morbid obesity, the patient is suffering from the following co-morbid conditions: [insert

conditions, e.g. exertional dyspnea, urinary incontinence, obstructive sleep apnea, hypertension,

diabetes, degenerative joint disease, osteoarthritis, hypercholesterolemia, hyperlipidemia, shortness of

breath, etc].

The patient has tried many methods of weight loss including appetite suppressants for [iF appetite

suppressants were tried - insert length of time], with [insert number of pounds lost and whether they were

regained or not], physician-administered diet plans for [insert length of time] and [insert number of pounds

lost and whether they were regained or not], Weight Watchers, etc. The patient is limited due to his/her

co-morbidities in his/her ability to exercise but has tried [list all attempts and any successes or regaining

of weight].

Family medical history is positive for [insert medical conditions, e.g. obesity, hypertension, diabetes,

hypercholesterolemia, etc].

I am supportive of this patient’s desire to proceed with Bariatric surgery. The patient has a good

understanding of the risks involved and reasonable expectations and understands the importance

of being compliant with all post-surgical requirements. I will also continue to support this patient’s primary

care needs should they proceed with surgical intervention. I am respectfully requesting consideration for

Bariatric surgery.

Thank you for your attention in this matter.

Sincerely,

[signature and typed name of PCP]

[Pepper123 320]

MY PCP bless her filled it out…. she even added all my previous weights and that was very helpful…those past weights were all accepted by my insurance...

[TEXASLADY52 264]

I was also instructed to write a letter to the insurance company (Dr office submitted it with their paperwork)...hope this helps:

To Whom It May Concern:

I originally had a VBG (Vertical Band Gastroplasty Stapling) in 1980

Following the surgery of the VBG I was very compliant with the post-operative directions, including but not limited to:

 Not "over-eating"

 Not drinking during meals

 No carbonated drinks

 Exercised and tried to walk at least a mile or more every day

 Attended all follow-up appointments

I never was able to lose any countable amount of weight. The stapled band was too loose and there was no way to adjust it, therefore there was very little restriction, causing poor weight loss. I vomited regularly until the staple line dividing the stomach broke down. The VBG is now causing a lot of concern. The staple line came completely apart and I now have two separate pouches for a stomach. Per Dr. xxxxx M.D., this is why I cannot lose weight and will never be able to lose the weight.

This has nothing to do with compliance and has caused a great deal of pain and discomfort. I still suffer with acid reflux, heartburn, spasmodic esophagus and vomiting. Dr. xxxx also diagnosed me with H Pylori gastritis. My stomach problems gets worse when it is empty and improves when I eat food or drink milk, which then I get diarrhea. The bacteria can also attach to cells of the stomach, causing stomach inflammation and can stimulate the production of excess stomach acid. Over time, this with the bacteria can increase my likely hood of developing stomach cancer.

Over the years I have done everything I can to control my weight and have failed at all attempts. I can lose some weight, but then I gain it all back and more. With my severe morbid obesity, I suffer with diabetes, arthritis, high blood pressure, anxiety, panic attacks and neuropathy. I am having significant adverse symptoms from my obesity. I have difficulty standing and walking. I have difficulty performing any daily activities and in participating in any family activities. I have intolerable problems with the constant pain of the weight-bearing joints. If I continue the way I am, I will have to have both knees replaced. I have already had three gel shots at the cost of $2000 each trying to be able to keep walking and am in the need of shots in each knee again at this time.

I have sleep apnea and have been diagnosed with Obesity Hypoventilation. I suffer severe episodes of drowsiness, or narcosis and unable to drive a car a long distance.

The way I am right now, I might have five years to live. I don’t want to face the possibility of cancer and I would like to get to the point that I am healthy and add twenty or more years to my life.

Sincerely,

Edited August 14, 2014 by TEXASLADY52