has attended a comprehensive diabetes self management training program, and Drivers with Type 1 diabetes should carry a glucagon emergency kit. …
SAMPLE PCP LETTER
This is a sample letter for you to share with your PCP It gives them an
idea of the kind of detailed information we will need from them for
insurance approval
To Whom It May Concern:
I am writing this letter on behalf of my patient ————— who is a X
year old white female/male with history of morbid obesity, diabetes,
hypertension, hyperlipidemia, arthritis, fallen arches in her feet which
has caused her serious foot problems and impairs her ability to do her job,
sleep apnea which includes the inability to sleep in a bed for the last 8
years, she has to sleep upright in a chair She has also suffered from
depression related to these issues and has had recurrent falls
Ms——– has chronically been dealing with her weight issues She has
participated in Weight Watchers several times; she has tried the Mayo
Clinic diet off and on for the past 6 years She has tried Dr Atkins diet,
water aerobics and Xenical with very little success She has lost 40 pounds
on past attempts but has gained it all back and sometimes more She even
had a stomach banding procedure in 1984, which had to be reversed in 1989
due to the torsion of the stomach and adhesions
After this surgery is the
only time she had much success and she was tolerating it well until the
post surgical complications During the time I have known her since 2001,
she has weighted on average between 301 - 338 despite all of her efforts
Her most recent weight in my office was 335 and she is 53 Her ideal body
weight would be 115
She is currently on the following medications: HCTZ, Actos, Lipitor,
Amaryl, Metformin, Zestril, Paxil Her diabetes is currently under good
control but she does show signs of diabetic nephropathy and proteunuria
This can also be affected by the obesity It is my hope that with dramatic
weight loss she would be able to be off most of her medications and have
resolution of many of her problems
Ms —- has carefully researched her options and understands the inherent
risks of the planned procedure With her multiple medical problems and her
attempts to loose weight I suspect surgery is the last resort for her I
hope you will give consideration for approval for the bariatric surgery by
Dr Sweeney If I can be of further help please do not hesitate to call
Source:state.hi.us
