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.
Identification of the procedure and diagnosis (per WPATH SOC p. 28)
- The duration of the provider’s relationship with the patient
- That the patient has gender dysphoria
- Procedure needed (permanent facial hair removal)
Hormone use
- List any hormone treatments
- Date started
- That they take the hormones consistently and appropriately
- Hormone therapy cannot eliminate facial hair
- Hormones have not decreased facial hair sufficiently to alleviate gender dysphoria
Comment on any other symptoms you are aware of such as
- Dysphoria specifically related to the facial hair
- Using makeup to hide beard shadow
- Limiting social activities as a result of facial hair
Capacity to make a fully informed decision and to consent for treatment
- Patient has capacity to make a fully informed decision
- Patient has provided informed consent for hair removal
Statement of medical necessity
- Indicate if you recommend permanent hair removal
- If you find it to be accurate, use the phrase “medically necessary,” which is defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
- That hair removal is performed to treat gender dysphoria
- Indicate if hair removal will help to alleviate the person’s gender dysphoria
- If you have seen other patients benefit from facial hair removal, indicate 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
Updated on Nov 19, 2020