Gender Reassignment Surgery Authorization Form

The app details requirements for requirements for mastectomy (female-to-male patients), requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female), requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female-to-male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male-to-female), characteristics of a qualified mental health professional, format for referral letters from qualified health professional and dsm 5 criteria for gender dysphoria in adults and adolescents. The app should be completed by the clinician who has a thorough knowledge of the member’s current clinical presentation and his/her treatment history. Please complete all parts as clearly and specifically as possible. Omissions, generalities and illegibility will result in the form being returned for completion or clarification.