Integrative Medicine Referral/Co-Management Letter (PCP or Specialist)

Date: [Date]

From: [Clinician name, credentials, specialty, organization, contact info]

To: [Receiving clinician name, credentials, specialty, organization]

Re: [Patient full name, DOB, MRN]

Dear Dr. [Receiving clinician last name],

Reason for Referral

[Primary referral reason in one concise sentence]

Urgency: [routine / urgent] — [requested timeframe] (If urgent, briefly note the specific safety concern.)

Specific requests/questions:

• [Clinical question/request]
• [Additional clinical question/request] (Include as needed.)

Clinical Summary

[Patient snapshot: age, relevant demographics, key diagnoses, current main concern]

• [Key active problems, prioritized by acuity]
• [High-risk flags affecting management: e.g., anticoagulation, pregnancy/lactation, CKD/liver disease, immunosuppression, active cancer therapy, planned procedures, psychiatric or substance use risk factors] (If unknown but safety-relevant, document as "Unknown/not assessed.")

[Brief HPI: onset, course, prior treatments tried and response, current functional impact] (Limit to 1–2 sentences.)

[Patient goals and preferences relevant to the referral question] (Include only if applicable.)

Allergies/adverse reactions: [Allergen — reaction type] (If none, state "None known." If unknown, state "Unknown/not assessed.")

Current Therapies

(List all therapies relevant to safety and the referral question. If details are unknown, state "unknown" rather than omitting.)

Conventional medications:

• [Generic name — dose, route, frequency; indication; adherence/adverse effect notes if relevant]

Supplements and integrative products: (Include vitamins/minerals, botanicals/herbals, probiotics, homeopathic products, TCM/Ayurvedic formulas, cannabis/CBD.)

• [Product name (brand if known) — dose or "unknown dose," route, frequency; intended purpose; duration; key active ingredients if multi-ingredient]

Non-pharmacologic therapies:

• [Modality — frequency; response]

Assessment & Plan

Interaction review: [performed / not performed] (Note any limitations due to incomplete supplement details or unverified products.)

• [Safety concern: agent/condition combination and specific risk] (Include only if identified.)

Working assessment: [Concise assessment linking clinical picture to the referral question]

Roles: Integrative clinician will manage [ongoing management responsibilities]. Requesting [specific evaluations/treatments/monitoring from receiving clinician].

Follow-up: [Planned follow-up timing]. Preferred communication: [secure message / phone / EMR note] at [contact details].

Integrative framework impression: [TCM/Ayurveda/functional medicine framing with translation to clinically actionable terms] (Include only if relevant; label clearly as integrative framework, not established biomedical pathology.)

Sincerely,

[Sender name, credentials]
[Title/Role]
[Organization]
[Contact information]