What is the purpose of this form?

The form documents clinical facts and procedural details necessary for payers to determine coverage and medical necessity for gender-affirming surgery. It centralizes required records so reviewers can make an informed decision without repeated requests for missing information.

Who must sign and attest?

The treating surgeon or authorized clinician should sign the provider attestation. The patient or authorized representative signs any consent or release sections. Ensure signatures include credentials and dates to support clinical statements.

Can the form be e-signed and submitted electronically?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA when the transaction shows intent, consent, attribution, and reproducible retention. For PHI, use a platform offering a BAA and secure storage.

What supporting documents are typically required?

Attach recent clinical notes, psychiatric evaluations when requested, hormone therapy documentation, and any imaging or lab results that substantiate the diagnosis and readiness for surgery.

How long will the payer take to decide?

Decision times vary by payer; many non-urgent reviews target about 30 days, and expedited reviews may be completed in 72 hours. Always check the member’s plan for specific turnarounds and urgent criteria.

What if the authorization is denied?

Review the denial rationale, assemble any missing clinical evidence, and file an internal appeal within the insurer’s stated timeframe. Consider external review or legal counsel for complex denials involving coverage disputes.

Electronic Signature
Templates
Education
Gender Reassignment Surgery Precertification Information Request Form

Gender Reassignment Surgery Precertification Information Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Gender Reassignment Surgery Precertification Information Request Form

PCFX

Applies to:

Aetna plans

Innovation Health® plans

Health benefits and health insurance plans offered, underwritten, and/or administered by the following:

Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)

Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner | Aetna)

Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)

Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna)

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates.

About this form

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. Failure to complete this form and submit all of the medical records we are requesting may result in the delay of review.

Effective May 24, 2018, this form replaces all other gender reassignment surgery precertification information request documents and forms. This form will help you supply the right information with your precertification request. You don’t have to use the form. But it will help us adjudicate your request more quickly.

How to fill out this form

As the patient’s attending physician, you must complete all sections of the form.

You can use this form with all Aetna health plans, including Aetna’s Medicare Advantage plans. You can also use this form with health plans for which Aetna provides certain management services.

When you’re done

Once you’ve filled out the form, submit it and all requested medical documentation to our Precertification Department by:

• (Preferred) Upload your information electronically on our secure provider website on NaviNet® at connect.navinet.net.

o Complete a Precertification Inquiry transaction for the patient.

o When the inquiry is successful, click the “Add Attachment” link in the upper right corner of the screen.

o Upload your document(s) and click “Attach.” The window will close and you will return to Precert Inquiry screen.

• Send your information via confidential fax to:

o Precertification – Commercial Plans: 859-455-8650

o Precertification - Medicare Advantage Standard Organization Determination: 859-455-8650

o Precertification - Medicare Advantage (expedited only): 860-754-5468

• Mail your information to: PO Box 14079 Lexington, KY 40512-4079

What happens next?

Once we receive the requested documentation, we’ll perform a clinical review. Then we’ll make a coverage determination and let you know our decision. Your administrative reference number will be on the electronic precertification response.

How we make coverage determinations

If you request precertification for a Medicare Advantage member, we use CMS benefit policies, including national coverage determinations (NCD) and local coverage determinations (LCD) when available, to make our coverage determinations. If there isn’t an available NCD or LCD to review, then we’ll use the Clinical Policy Bulletin referenced below to make the determination.

For all other members, we encourage you to review Clinical Policy Bulletin #615: Gender Reassignment Surgery, before you complete this form.

You can find the Clinical Policy Bulletins and Precertification Lists by visiting the website on the back of the member’s ID card.

Questions?

If you have any questions about how to fill out the form or our precertification process, call us at:

• HMO plans: 1-800-624-0756

• Traditional plans: 1-888-632-3862

Gender Reassignment Surgery Precertification Information Request Form

Section 1: Provide the following general information

Member name:

Administrative reference number (required):

Member ID:

Member date of birth:

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? No Yes

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

Does the patient currently have significant medical concerns? No Yes

If yes, are they reasonably well controlled? No Yes

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

If yes, are they reasonably well controlled? No Yes

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

Is the request for female-to-male services? No Yes If yes, go to Section 3.

Is the request for male-to-female services? No Yes If yes, go to Section 4.

Section 3: Provide the following patient-specific information

Select the requested service(s):

Mastectomy

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

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? No Yes

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

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

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? No Yes

Section 4: Complete this section if request is for male-to-female 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? No Yes

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

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

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? No Yes

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.

Signature of treating doctor or other qualified healthcare provider:

Date:

Contact name of office personnel to call with questions:

Telephone number:

What this Precertification Information Request Form Is

The Gender Reassignment Surgery Precertification Information Request Form is a clinical and administrative packet used by providers to request insurer review and prior authorization for gender-affirming surgical procedures. It consolidates patient identifiers, clinical history, diagnostic codes, procedure codes, supporting clinical notes, and provider attestation so payers can evaluate medical necessity. The completed form helps standardize insurer review, speeds routing of documentation, and serves as the primary record for authorization decisions, appeals, and scheduling while preserving required clinical detail for utilization management.

Why this Form Matters and Its Legal Basis

The form documents clinical justification and administrative details insurers need to approve gender-affirming surgery and reduces avoidable denials. Electronic completion and retention meet ESIGN (15 U.S.C. ch. 96) and UETA standards when intent, consent, attribution, and record retention are present, and HIPAA safeguards must protect patient health information.

Who completes and who receives this form

Typical users include the operating surgeon, clinic administrative staff, and the patient’s insurer or utilization review team.

Surgeons and surgical schedulers who compile clinical notes and procedure details for prior authorization.
Clinic billing and utilization staff who confirm codes, attach records, and transmit the packet to payers.
Insurer clinical reviewers and medical directors who assess medical necessity and issue authorization determinations.

Accurate completion by clinical and administrative teams reduces processing delays and helps preserve appeal rights if authorization is denied.

Primary signers and responsible parties

Primary Surgeon

The surgeon signs the provider attestation and confirms clinical indications, prior treatments, and the planned procedure. Their signature establishes medical necessity and documents that the clinician reviewed records and supports the request for authorization.

Patient / Authorized Rep

The patient or an authorized representative signs consent and demographic declarations where required. That signature confirms identity, informed consent for release of medical records, and authorization to proceed with insurer communications.

Essential sections to include in a professional packet

A well-constructed precertification packet groups clinical and administrative content so reviewers can make an evidence-based determination without repeated follow-up. Each section should be concise and clearly labeled.

Patient Identifiers

Full legal name, DOB, medical record number, payer ID, and contact details to ensure the request matches the insurer’s member record and avoids duplicate or misrouted reviews.

Clinical History

Concise summary of gender dysphoria diagnosis, prior mental health or hormone therapy, duration of treatment, and documented readiness consistent with professional guidelines.

Procedure Details

Planned procedure name with CPT/HCPCS codes, laterality, operative plan, and expected LOS or outpatient status so payers can map to benefit coverage rules.

Supporting Documentation

Attach recent clinical notes, psychiatric evaluation if required, hormone therapy records, imaging, and any relevant correspondence that substantiates medical necessity.

Provider Attestation

Signed statement from the treating surgeon or authorized clinician affirming diagnosis, clinical indications, and that the procedure is appropriate and supported by records.

Billing & Prior Auth Info

Include requested authorization dates, estimated procedure cost or CPT quantity, billing NPI, taxonomy, and contact information for authorization follow-up.

How to complete and submit the form: step-by-step

Follow a clear sequence: collect records, complete the form, attach supporting documentation, obtain signatures, and submit to the insurer through the designated channel.

01

Gather Records: Collect recent clinic notes, psychiatric letters, and hormone therapy documentation.
02

Populate Form: Enter identifiers, diagnosis, procedure codes, and provider attestation.
03

Attach Evidence: Upload relevant clinical notes, imaging, and mental health evaluations.
04

Submit and Track: Send via payer portal, secure fax, or authenticated eSubmission and retain confirmation.

Configuring an online workflow for this form

Set up fields, signer roles, and routing logic so the form flows from clinician to billing staff to payer without manual handoffs.

Field	Configuration
Authentication	Email link or SMS code with optional advanced signer verification
Template	Lock required fields and reuse the template across patients
Conditional Logic	Show psychiatric evaluation field only when required
Notifications	Auto-notify clinician and billing staff on submission and payer response

Typical routing and submission destinations

Understand common submission channels so you choose the fastest, most reliable delivery method accepted by each payer.

Payer Portal: Direct upload to insurer’s prior-authorization portal when available
Secure Fax: Encrypted or HIPAA-compliant fax for payers that require faxed requests
Email with Encryption: Secure, encrypted email for plans that permit electronic attachments
Third-Party Clearinghouse: Submit via an authorized medical clearinghouse or utilization management vendor

Technical and format considerations for electronic submission

Choose file formats and integrations that meet payer requirements and protect PHI during transmission.

Supported Formats: PDF and DOCX are standard for attachments
Integrations: Works with EHR, Google Workspace, and major cloud storage
Authentication: Email link, SMS code, or advanced methods available

Ensure the chosen platform supports HIPAA safeguards (BAA where needed), preserves audit trails, and produces a tamper-evident signed record for payer review and appeals.

Timing, expected processing windows, and urgent review options

Processing times vary by payer and plan; plan documents and clinical urgency determine standard and expedited timelines.

Standard Decision Time:

Many insurers aim to complete non-urgent prior authorization reviews within 30 days; check the member’s plan for exact timelines.

Expedited Review:

For urgent clinical need, some payers allow expedited review with decisions often within 72 hours; confirm requirements with the insurer.

Submission Lead Time:

Submit well before the planned surgery date; many facilities recommend 30–60 days to allow scheduling and appeals.

Appeal Deadlines:

Appeal filing windows commonly range from 30 to 60 days after denial; refer to the insurer’s denial letter for firm deadlines.

Follow-up Tracking:

Document confirmation numbers and contact points; timely follow-up reduces administrative delay.

Key milestones from request to authorization

Track these stages to monitor progress and prepare for each required action or document exchange.

01

Pre-Submission Prep

Assemble records, confirm codes, and obtain clinician signature before sending

02

Submission

Send to payer by portal, secure fax, or encrypted email and save confirmation

03

Clinical Review

Payer medical review assesses documentation for medical necessity and coverage

04

Decision & Notice

Payer issues authorization or denial and provides appeal instructions if denied

Common errors that cause delays or denials

Incomplete clinical histories or missing psychiatric evaluations lead to requests for additional information and extended review times.
Incorrect or missing CPT/ICD codes cause routing errors or mismatched benefit rule checks and may trigger denials.
Mismatched patient identifiers between the form and insurer records lead to eligibility verification failures and processing delays.
Omitting provider attestation or unsigned pages often requires re-submission and can void an otherwise approvable request.

Consequences of incorrect or incomplete submissions

Claim Denial: May result in out-of-pocket liability

Surgery Delays: Procedure scheduling can be postponed

Appeal Costs: Administrative and clinical time increases

Audit Exposure: Incomplete records can trigger retrospective review

HIPAA Risk: Improper PHI handling increases breach risk

Provider Liability: Inaccurate attestations carry professional risk

eSignature vendor comparison for precertification workflows

Compare basic pricing and compliance features for common eSignature vendors when selecting a platform to sign and store sensitive clinical authorizations.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Practical tips to reduce denials and speed decisions

Adopt standardized templates, validated code sets, and digital workflows to minimize follow-up requests and preserve appeal windows.

Assemble a Complete Packet

Include clinical notes, relevant psychiatric assessments, hormone therapy history, imaging, and clear CPT/ICD coding to avoid downstream information requests.

Use Standard Codes

Validate CPT and ICD-10 codes against current coding references and payer rules before submission to reduce administrative rework.

Secure PHI

Transmit documents using HIPAA-compliant tools with a BAA and ensure audit trails capture signer attribution and timestamps.

Track and Document

Record submission confirmations, reviewer contacts, and appeal deadlines so follow-ups are timely and documented.

Illustrative scenarios of form use

Realistic examples show how clinics assemble records and how insurers may process the request.

Outpatient Clinic Workflow

A surgeon prepares the packet with psychiatric and hormone therapy notes

The billing team submits via payer portal with CPT/ICD codes
The clinic retains confirmation and schedules once authorization is received, reducing cancellations and rescheduling.

Hospital Pre-Op Coordination

A hospital case manager gathers surgical plan, imaging, and provider attestation

The insurer requests an additional operative note
The hospital provides the note and receives timely authorization for inpatient scheduling.

Frequently asked questions and troubleshooting

Answers to common questions about completion, submission, and electronic validity to help clinical and administrative staff avoid delays.

Need help? Contact support

What is the purpose of this form?
The form documents clinical facts and procedural details necessary for payers to determine coverage and medical necessity for gender-affirming surgery. It centralizes required records so reviewers can make an informed decision without repeated requests for missing information.
Who must sign and attest?
The treating surgeon or authorized clinician should sign the provider attestation. The patient or authorized representative signs any consent or release sections. Ensure signatures include credentials and dates to support clinical statements.
Can the form be e-signed and submitted electronically?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA when the transaction shows intent, consent, attribution, and reproducible retention. For PHI, use a platform offering a BAA and secure storage.
What supporting documents are typically required?
Attach recent clinical notes, psychiatric evaluations when requested, hormone therapy documentation, and any imaging or lab results that substantiate the diagnosis and readiness for surgery.
How long will the payer take to decide?
Decision times vary by payer; many non-urgent reviews target about 30 days, and expedited reviews may be completed in 72 hours. Always check the member’s plan for specific turnarounds and urgent criteria.
What if the authorization is denied?
Review the denial rationale, assemble any missing clinical evidence, and file an internal appeal within the insurer’s stated timeframe. Consider external review or legal counsel for complex denials involving coverage disputes.

Explore Templates

Release and Authorization to Record Picture and Voice Sample Letter for Disputing a Debit Card Charge Agreement of Accord and Satisfaction Survivors Assistance Guide for Veterans and Their Families Sample Letter to Insurance Company Notifying of Death Independent Contractor Agreement

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now