Cancer Policy Lab
For clinicians

Medical frailty letter builder

Fill in the form and the letter writes itself below, using the federal rule's own wording. Copy it into your letterhead or print it, then sign it.

Nothing you type is saved or sent. The letter is built in your browser and disappears when you close the page. Still, follow your institution's rules for handling patient information on shared computers.

Check your state's form first. Some states require their own medical frailty form; if so, use this letter as an attachment or as wording for that form.

1. Fill in

Patient and treatment

Include codes for metastatic disease if present (C77–C79), since some states' lists count them.
Serious or complex medical condition: the condition… (check all that apply; wording from 42 CFR 435.554(c)(5)(i)(E))
Other federal frailty categories, if they apply (42 CFR 435.554(c)(5)(i)(A) and (D))
How it limits the patient's ability to work (check all that apply)
2. Review and send

Your letter

Before you send it: read every sentence and change anything that does not match the patient. Send it the way your state accepts documents (online portal, fax or mail), give the patient a copy, and note in the chart that it was sent and when.

Write a new letter when the treatment plan changes, and at least once a year, since states must recheck frailty every 12 months. The letter only states what you check; leave a box unchecked if you are not sure it applies.