Services

Sample letters:

[must be on letterhead]

[date]

Re: [patient name on insurance card], [patient's chosen name], [patient DOB]

To Whom it May Concern,

[Patient name] is a patient in my care at [your practice name]. They have been a patient here since [date]. They identify as [gender identity] and go by [pronouns]. They note that they first knew their gender identity differed from their assigned sex at age [age]. They have socially transitioned by [list how-changed name, pronouns, dress, make-up, hair, tuck, pack, binding, coming out, etc.). They have been successfully and consistently living in a gender role congruent with their affirmed gender since [date]. They have been consistently on hormone therapy since [date] (If contraindicated or chosen not to take hormones, state that here). Despite these interventions, they report significant anxiety, depression and distress due to their experience of dysphoria. By my independent evaluation of [patient name], I diagnosed them with Gender Dysphoria

(ICD-10 F64.1). They have expressed a persistent desire for [type of surgery]. Their goals of surgery are [goals]. Surgery will address their gender dysphoria in these ways: [explain].

[Patient name] is psychologically stable to undergo this surgery. [list any mental health diagnoses that may be relevant to having surgery]. They are stably housed and have prepared for their post-op recovery [if this is true; if not, state plan for post-op recovery]. They have no issues with illicit drug use or abuse [if this is true; if not, explain plan of care for stabilization].

[Patient name] has more than met the WPATH criteria for [type of surgery]. I have explained the risks, benefits and alternatives of this surgery and believe they have an excellent understanding of them. [If risks, benefits and alternatives are unknown, please state they will be discussed at consult.] They can make an informed decision about undertaking surgery. I believe that the next appropriate step for them is to undergo [type of surgery],

and I believe this will help them make significant progress in further treating their gender dysphoria. I am available for coordination of care and ongoing treatment as needed and welcome a phone call to establish this. Therefore, I hereby recommend and refer [patient name] to have this surgery.

If you have questions or concerns, please do not hesitate to contact me.

Sincerely,
[your name and credentials] [your phone number]

Example Certification from Attending Physician

(Attending Physician's Official Letterhead)

I, (physician's full name), (physician's medical license or certificate number), (issuing State of medical license/certificate), (DEA Registration number), am the attending physician of (name of patient), with whom I have a doctor/patient relationship.

(Name of patient) has had appropriate clinical treatment for gender transition to the new gender (specify new gender male or female).
Or
(Name of patient) is in the process of gender transition to the new gender (specify new gender male or female).

I declare under penalty of perjury under the laws of the United States that the forgoing is true and correct.

Signature of Physician Typed Name of Physician Date

Sample Letter 2 from Licensed Physician

(Physician's Address and Telephone Number)

I, (physician's full name), (physician's medical license or certificate number), (issuing U.S. State/Foreign Country of medical license/certificate), am the physician of (name of patient), with whom I have a doctor/patient relationship and whom I have treated (or with whom I have a doctor/patient relationship and whose medical history I have reviewed and evaluated). (Name of patient) has had appropriate clinical treatment for gender transition to the new gender (specify new gender, male or female).

I declare under penalty of perjury under the laws of the United States that the forgoing is true and correct. Signature of Physician
Typed Name of Physician
Date