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The template requests inclusion of patient identifiers (full name and date of birth) and a licensed mental health professional signature on office letterhead. It guides documentation of decision-making competency, substance abuse history and stress handling, relevant psychiatric diagnoses with prognosis and treatment advice, coping mechanisms, ability to manage treatment-related stress, and suitability as a surgical candidate. It also specifies required clinical sections, including psychiatric and medical history, social and occupational history, mental status exam, family history, review of systems, functional assessment, and submission by email or fax.","| DATE: |  |\n| --- | --- |\n| TO:\u003Cbr>ATTN: | Fax: |\n| From:\u003Cbr>BODY BY BARIATRICS, LLC |  |\n| Pages (including cover): 2 |  |\n| REQUEST: Psychological Evaluation – Bariatric\u003Cbr>Surgery PATIENT:\u003Cbr>DOB:\u003Cbr>Your patient has chosen BodyByBariatrics Weight Loss and Bariatric Surgery Program to start living a healthier lifestyle. One of their insurance carrier requirements is a psychological evaluation from a licensed mental health professional. Please review the following criteria that needs to be included in the letter. If you have any questions regarding this letter, please feel free to contact our team. |  |\n\nThe information contained in this message may be privileged and/or confidential and protected from disclosure. If the reader of this message is not the intended recipient or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of the communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately by replying to this message and deleting the material from any computer.  \nPatient Name:    \nDOB:    \nThe following information must be included to obtain a Psychological Evaluation for Bariatric Surgery for the treatment of morbid obesity (E66.01) .  \n• Letter typed on your office letterhead and signed by a licensed mental health professional  \n• Patient’s full name and date of birth  \n• What is the patient’s competency in deciding to proceed with weight loss surgery?  \n• Is there a history of substance abuse or dependence? If so, how will this patient be able to handle the stress of weight loss?  \n• Are there any psychiatric diagnoses that are relevant to weight loss surgery?  \nIf so, please provide prognosis and treatment advice.  \n• What is the patient’s ability to handle the stress of weight loss surgery?  \nWhat are the patient’s coping mechanisms?  \n• Should the patient be seen for further counseling or medication adjustments for weight loss surgery?  \n• In your professional expertise, do you feel this patient is an appropriate candidate for weight loss surgery?  \n• Please also include:  \no History of present illness  \no Past psychiatric history  \no General medical history  \no Social history  \no Occupational history  \no Mental status examination  \no Family history  \no Review of systems  \no Functional assessment  \nPlease kindly send this letter of medical necessity by email ([Support@BodyByBariatrics.com](Support@BodyByBariatrics.com)) or via fax (407-707-8658) .","cbCaialOw8WofgSh","https://ap.wps.com/l/cbCaialOw8WofgSh","pdf",153717,2,"English","en",105,"# REQUEST\n## Inclusion Criteria\n## Required Clinical Sections\n## Submission Instructions","[{\"question\":\"What does this psychological evaluation letter template require for bariatric surgery insurance approval?\",\"answer\":\"It requires a letter on the provider’s letterhead signed by a licensed mental health professional and the patient’s full name and date of birth, along with specific clinical and professional assessment criteria.\"},{\"question\":\"Which psychological and behavioral topics must be addressed in the evaluation?\",\"answer\":\"The template asks about the patient’s competence to decide on weight loss surgery, substance abuse history and stress handling, relevant psychiatric diagnoses with prognosis and treatment advice, coping mechanisms, and the ability to manage stress related to surgery.\"},{\"question\":\"What additional clinical sections does the letter request beyond the core assessment questions?\",\"answer\":\"It requests history of present illness, past psychiatric and general medical history, social and occupational history, mental status examination, family history, review of systems, functional assessment, and recommendations regarding further counseling or medication adjustments.\"}]","Psychological Evaluation Template - 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