Sample Psychiatric Clearance Letter for Bariatric Surgery

How to Write a Psychiatric Clearance Letter for Bariatric Surgery (With Free Samples)

In recent times, patients that seek to have bariatric surgery are mandated to undergo psychiatric screening. To experience this procedure, one is required to go through evaluation with medical or psychiatric expertise. This examination of the patient measures their mental wellbeing, which will ascertain their appropriateness for the surgery. When the physician feels the patients need the surgery, then will issue a psychiatric clearance letter.

A psychiatric clearance letter for bariatric surgery is an approval letter written by a physician with a patient medical history approving that the patient is fit to undertake the bariatric surgery ( weight loss surgery).  The physician or mental health professional uses two methods to examine candidates for bariatric surgery. One way is to interview the candidate to determine psychosocial factors to compromise surgery or thought to contraindicate it. The other method is through administering symptom inventories to screen for cognitive function and testing of psychopathology personality.

A psychiatric clearance letter is prepared before any weight-loss surgery and can be designed by a licensed clinical psychologist to a bariatric surgeon. The most significant reason for this clearance letter is that the entire team of healthcare professionals, which includes the surgeons, health care providers, and dietitians, down to the nurses, would help the candidate maximize success.

The letter will detail the following information: the candidate’s history of weight-loss-related health problems will be listed, the current weight and BMI, The previous weight loss attempts, and why the candidate should undergo the bariatric surgery. The clearance letter will help ascertain the strengths of the candidate and areas that would be needed after the surgery.

For a psychiatric clearance letter for bariatric surgery to be valid, the letter should be on the physician’s or mental health provider’s letterhead, dated, have the to whom it may concern title, have the full name of the patient as well as all the patient’s previous medical history.

Before a psychiatric clearance letter is issued, there are other paperwork that will be done before or after the issuing of the clearance letter. This includes overall assessment by the bariatric surgeon, and then a letter of medical necessity follows before a psychiatric evaluation and the mental health clearance letter and after the surgery follows a nutritional evaluation with a post-surgery eating advice from a registered dietician.

All the listed letters are official documents that need a professional tone, as such there are all formal letters. This simply means there need to take the formal method of communication. The clearance letter must be brief and straight to the point.

Below are samples format as a guide


Making it happen as anticipated

The blooming weight management center


Dr Forman Fredrick, CEO

5768, Spring Road, suite 243

Atlanta, Georgia 33454

Phone:   123-765-435

Fax:         343-546-232

We are in need of a letter of medical Necessity for Christine Bach

For your convenience, we have provided this template that you may use when producing your letter. Please fax us a typed letter, on your letterhead, as soon as possible for our above-named, mutual patient. This is required to submit for insurance approval

Thanks you for your assistance

Dr. Fredrick

Weight loss management center


Re:     Christine Bach

5th August 1970

To whom it may concern

Our office has seen the above-named patient for 4 years. She is suffering from the following comorbidities (sleep apnea, hypertension and degenerative joint disease etc. her current weight is 120ibs, and BMI is 95.8. this patient has undergone the following weight-loss attempts jenny Craig, weight watchers and slim fast. I feel this patient would benefit from weight loss surgery because she has been not be successful losing weight with other weight loss methods. Her medical conditions are becoming life threatening, and she needs to get help to keep her weight under control. I will be grateful if she considers this for approval. Please feel free to contact me for any further information


Dr. Fredrick


Sample 2 Format

Mailing Address:

Division of gastrointestinal and bariatric surgery

453 Minnie drive, Florida 65678

Office: 786-654-678

Fax:    612-678-876


Life-saver care centre

University of Florida

Medical center

Dear psychiatrist,

We have a mutual patient with morbid obesity Trish Wilber.  Who is looking to undergo bariatric surgery. A psychological evaluation has been done to see if this patient is good from any psychological perspective to undergo the elective surgery. All the same, we need your assistance with a letter of approval. Your input will be helpful and will affect our decision to hold or proceed with,

5th June 2021

Dr. Hart Lucas

Spring life medical centre

Re: Trish Wilber

4th may 1988


To whom it may concern

Our office has seen the above named patient Trish Wilber for 2 years. She has been suffering from morbid obesity, which became worse with diabetes and high blood pressure. Her present weight is 115kg with a BMI of 54kg. The patient was already on the following weight-loss treatment HMR, nutrisystem and weight watcher. I’m sure that she will fare well with a weight loss surgery because she has been unsuccessful losing weight with other diet methods. I think her medical conditions might deteriorate and become life threatening without a quick intervention. She needs to get her weight to a better level. I will appreciate consideration for approval. Please feel free to contact us when necessary

Yours sincerely

Dr. Hart Lucas


The fact is that all patients that need to undergo a bariatric surgery must have a psychiatric or psychological clearance. This has been a recommendation by the American Society for Bariatric surgery. This evaluation is a critical step that is not only to identify the patient contradictions for surgery but to assess their levels of readiness, motivation, and even adjustment during the surgery. This letter is always written by a licensed physician to bariatric surgeon. The above letters will serve as a guide for a perfect way of getting it right with a psychiatric clearance letter for bariatric surgery.


Please enter your comment!
Please enter your name here