medical letter

The following is a sample medical letter that you can give to your child’s pediatrician, developmental pediatrician, etc. to type on their office letterhead. It will inform your insurance what therapies your child needs as a medical necessity. 
To Whom It May Concern:

I am the _____________ (PCP, Dev. Ped, etc) for _________ (child’s name). _________ (child’s first name) has autism (or PDD-NOS or Aspergers), which is a neurological condition. I have been part of _______ (child’s name) treatment team since _______ (date). As part of _______ (child’s name) treatment plan, I find the following services to be medically necessary:

1) ___________ (type of therapy), up to _____ hours per week
2) ___________ (type of therapy), up to _____ hours per week
3) ___________ (type of therapy), up to _____ hours per week

Sincerely,
(doctor’s signature)