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)