Gender Reassignment Form

Gender Affirming Surgery
Precertification Information Request Form

Fax to: Precertification Department    Fax number: 1-

Member name:

Reference Number:

Member ID:

Member date of birth:

Section 1: Provide the following general information

If submitting request electronically, complete member name, ID and reference number only.

Requesting provider/facility name:

Requesting provider/facility NPI:

Requesting provider/facility phone number:

Requesting provider/facility fax number:

Assistant/co-surgeon name (if applicable):

TIN:

Section 2: Provide the following patient-specific information

Is this a new or continued treatment? New Continued

Does the patient have persistent, well-documented gender dysphoria? Yes No

Does the patient have the capacity to make a fully informed decision and to consent for treatment? Yes No

Does the patient currently have significant medical concerns? Yes No

If yes, are they reasonably well controlled? Yes No

Does the patient currently have significant mental health concerns? Yes No

If yes, are they reasonably well controlled? Yes No

Does the patient have substance abuse and/or chemical dependency concerns? Yes No

Is the request for female-to-male/non-binary services? Yes No

Is the request for male-to-female/non-binary services? Yes No

Section 3: Complete this section if request is for female-to-male/non-binary services

Select the requested service(s)

Breast removal (transgender mastectomy)

Use Reduction Mammaplasty code as mastectomy code is not applicable to transgender female-to-male/non-binary breast surgery.

Does the patient have a single letter of referral from a qualified mental health professional? Yes No

Does the patient have persistent, well documented gender dysmorphia? Yes No

Does the patient have the capacity to make a fully informed decision and consent to treatment? Yes No

Is the patient at the age of Majority? (18 or older) Yes No

If no, what is date range of testosterone treatment? to

Does patient have significant medical or mental health concerns? Yes No

Gonadectomy (hysterectomy and oophorectomy) or Genital reconstructive surgery (vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, placement of a testicular prosthesis and erectile prosthesis)

Does the patient have two referral letters from qualified mental health professionals, one in a purely evaluative role? Yes No

Does the patient have 12 months of continuous hormone therapy appropriate for their gender goals? Yes No

If yes, please provide the start date:

If no, does the patient have a contraindication or is otherwise unable or unwilling to take hormones? Yes No

Please describe:

Genital reconstructive surgery only: Has the patient been living in a gender role that is congruent with their gender identity (real-life experience) for 12 months? Yes No

If yes, please provide the start date:

Section 4: Complete this section if request is for male-to-female /non-binary services

Select the requested service(s)

Orchiectomy or Genital reconstructive surgery (penectomy, vaginoplasty, labiaplasty and clitoroplasty)

Does the patient have two referral letters from qualified mental health professionals, one in a purely evaluative role? Yes No

Does the patient have 12 months of continuous hormone therapy appropriate for their gender goals? Yes No

If yes, please provide the start date:

If no, does the patient have a contraindication or is otherwise unable or unwilling to take hormones? Yes No

Please describe:

Genital reconstructive surgery only: Has the patient been living in a gender role that is congruent with their gender identity (real-life experience) for 12 months? Yes No

If yes, please provide the start date:

Breast Augmentation

Breast augmentation (implants/lipofilling) for male-to-female patients:

Does the member have a single letter of referral from a qualified mental health professional? Yes No

Does the patient have persistent, well documented gender dysmorphia? Yes No

Does the patient have capacity to make a fully informed decision and consent to treatment? Yes No

Is the patient the age of Majority? (18 or older) Yes No

Has the patient completed One (1) year of feminizing hormone therapy prior to breast augmentation? Yes No

Does the patient have significant medical or mental health concerns? Yes No

Section 5: Provide the following documentation for your request

Current history and physical

Office notes related to the patient’s condition

Description of proposed treatment

Mental health referral letter(s)

Documentation of mental health conditions, if applicable

Documentation of substance abuse/chemical dependency issues, if applicable

Documentation of hormone therapy, including duration, if applicable

Section 6: Read this important information

Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Section 7: Sign the form

Just remember: You can’t use this form to initiate a precertification request. To initiate a request, you have to call our Precertification Department. Or you can submit your request electronically.

Contact name of office personnel to call with questions:

Telephone number: 1-