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  • Current: Adult Hormone Replacement Therapy Checklist

Adult Hormone Replacement Therapy Checklist

Use this checklist to ensure that each element is included in your letter. Use language that is client specific; do not simply copy this checklist.


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Identification of patient and diagnosis

  • The client’s general identifying characteristics (age, gender, etc.)
  • The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date
  • Results of the client’s psychosocial assessment, including any diagnoses

Statement of Medical Necessity

  • Explain that WPATH criteria for hormones have been met. (p. S258, Appendix D of WPATH SOC v8, available here) Address each point of the WPATH Criteria:
    • Gender incongruence is marked and sustained
    • Meets diagnostic criteria for gender incongruence prior to gender-affirming hormone treatment in regions where a diagnosis is necessary to access health care
    • Demonstrates capacity to consent for the specific gender-affirming hormone treatment
    • Other possible causes of apparent gender incongruence have been identified and excluded
    • Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed
    • Understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options
  • Indicate you recommend initiating hormone replacement therapy
  • Use the phrase “medically necessary,” which is generally defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
  • Note harms associated with withholding or delaying hormone replacement therapy
  • If you have liaised with professionals from different disciplines within the field of trans health for consultation and referral, note that

State the qualifications of the provider

Discuss your credentials as applicable. Omit things that do not apply.
  • Education and degree
  • Licensure
  • Length of time & experience working with/diagnosing trans patients
  • Number/percentage of trans patients seen, if a significant part of your practice
  • Continuing education in the assessment and treatment of gender dysphoria;
  • Relevant professional associations
  • Relevant publications
  • Relevant trainings given, courses taught
  • Consider attaching CV if a specialist

If you need any additional information, please do not hesitate to contact me at [phone].

Sincerely,

Signature
Provider’s Name
Licensing information

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Updated on Mar 12, 2025

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