You can open the Gender Affirming Surgery Letter Template in multiple formats, including PDF, Word, and Google Docs.
Gender Affirming Surgery Letter Template Printable | Editable FormSample
Examples
[Name of the Patient]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email]
[Name of the Provider]
[Provider’s Title]
[Provider’s Address]
[Provider’s Phone Number]
This letter is to confirm that [Patient’s Name] is under my care for gender-affirming treatment. It outlines the medical necessity of gender-affirming surgery for the ongoing health and well-being of the patient.
[Patient’s Name] has been diagnosed with Gender Dysphoria as outlined in the DSM-5 criteria. The patient has actively participated in a comprehensive treatment plan, including but not limited to: [List treatments or therapies].
After thorough evaluation, I have prescribed the necessary steps for transitioning, including hormone replacement therapy since [Start Date of HRT], and the patient has shown satisfactory progress.
I strongly recommend gender-affirming surgery as it is medically necessary for [Patient’s Name] to alleviate their gender dysphoria and improve their mental health. Quoting the World Professional Association for Transgender Health (WPATH) guidelines, the patient meets all eligibility criteria.
I support [Patient’s Name]’s desires for gender-affirming surgery, which will provide significant psychological and emotional relief. Please feel free to contact me directly at [Provider’s Phone Number] or [Provider’s Email] should you require any further information.
[Signature of the Provider]
[Name of the Provider]
[Date]
[Name of the Patient]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email]
[Name of the Provider]
[Provider’s Title]
[Provider’s Address]
[Provider’s Phone Number]
This letter serves to officially document the medical necessity of gender-affirming surgery for [Patient’s Name].
[Patient’s Name] has undertaken a series of evaluations and treatments necessary for their transition, including individual counseling and hormone therapy since [Start Date of HRT].
After comprehensive assessments, I affirm that gender-affirming surgery is essential for [Patient’s Name] to achieve a body aligned with their gender identity and reduce associated mental health issues.
This recommendation adheres to the WPATH Standards of Care, ensuring that the patient’s needs are met with the highest priority and in accordance with ethical medical practices.
For further questions or clarity regarding the patient’s condition and treatment plan, please don’t hesitate to contact me at [Provider’s Phone Number] or [Provider’s Email].
[Signature of the Provider]
[Name of the Provider]
[Date]
Format
Please complete the form below to create the Gender Affirming Surgery Letter Template. All fields must be filled out to ensure a clear and complete letter. We provide examples to guide you through each step. Gender Affirming Surgery Letter Template 1. Patient Information 2. Provider Information 3. Medical Necessity Statement 4. Treatment History 5. Surgical Procedure Description 6. Informed Consent Statement 7. Follow-up Care Recommendations 8. Signature and Verification
PDF
WORD
Google Docs
Gender Affirming Surgery Letter Template Printable | Editable FormPrintable
