SAMPLE LETTER OF MEDICAL

NECESSITY

___________(Date)

RE: ________________(Patient Name)

I.D. # ___________

To Whom It May Concern:

Please accept this letter as a formal request for authorization for Roux-en-Y gastric bypass

surgery for my patient, ________________, ID#___________. He/She has been a patient of

mine since _______, has been morbidly obese for ____ years and has continually struggled to lose

weight. His/Her medical history indicates that she has tried many diets consecutively during the

past two (2) years under medical supervision, including, _________________for ____months;

______________for ____months, _______________ for ____months, ____________for

____months and low fat low calorie diets on and off since the age of _____. Although these

programs have initially shown promise, all ended in failure with little or no weight loss.

Mr./Ms. has been diagnosed with morbid obesity as well as _____________, ______________,

________________ and _______________. His/her co-morbid conditions are being treated with

________________________________________. His/her weight is ______ pounds, height

_____ with a BMI of _____.

I find this surgery to be a medical necessity and have referred Mr./Ms. ____________________

to Paul B. Wizman M.D., who specializes in laparoscopic Roux-en-Y gastric bypass surgery and

offers extensive pre and post-op education and follow-up care.

Should you have any questions regarding this recommendation, please feel free to contact me

directly.

Sincerely,

___________________, M.D.

_____________________________________________________________________________

2960 N. State Road 7, Suite 102, Margate, Florida 33063

954-969-1355 Fax 954-969-1232 www.DRWIZMAN.COM