---
title: Sample Email/ Letter Of Medical Necessity (Parent / Guardian)
description: Sample Email/ Letter Of Medical Necessity (Parent / Guardian)
---

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# Sample Email/ Letter Of Medical Necessity (Parent / Guardian)

 

**NOTE:** This sample letter is meant to guide you. You are welcome to use it as-is or personalize it in your own words to reflect your child’s needs.

**Date:** \_\_\_\_\_\_\_\_\_\_\_

**To:** TriCare Utilization Management Department

**Re:** Request for Out-of-Network Pediatric Psychiatry Services (Medical Necessity)

To whom it may concern,

I am the parent or legal guardian of a TriCare-insured child who requires ongoing pediatric psychiatric care.

My child has a documented medical need for psychiatric evaluation and/or medication management. After extensive efforts, we have been unable to locate an in-network child and adolescent psychiatry provider in our geographic area who can provide timely and appropriate care. In-network options have excessive wait times, are not accepting new pediatric patients, or are unavailable within a reasonable distance.

Due to this lack of access, my child is currently receiving care through **MindWeal Health**, a pediatric psychiatry practice that specializes in the evaluation and treatment of children and adolescents. Maintaining continuity of care is **medically necessary** for my child’s emotional health, stability, and overall well-being.

Disruption or delay of psychiatric care could result in worsening symptoms, academic difficulties, emotional distress, and increased risk of crisis-level care. For these reasons, continued access to pediatric psychiatric services is essential.

I respectfully request that TriCare approve **MindWeal Health** as an **Out-of-Network provider** for my child so that medically necessary psychiatric care may continue without interruption.

Thank you for your time and consideration.

Sincerely,

**Parent/Guardian Name:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  
**Child’s Name:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  
**Child’s Date of Birth:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  
**TriCare Member ID:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  
**Phone or Email (optional):** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ATTENTION:** This sample letter is provided for informational purposes only and does not guarantee coverage or authorization. Final determinations are made by TriCare.

 

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