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Hormone Replacement Therapy (HRT) Letter Criteria

Dr. Sidhbh Gallagher

These requirements are based on WPATH Standards of Care v.7 and are not generated by our office. As WPATH members we do follow these guidelines to move forward with consultations and surgery.

These are minimum standards and additional items could be requested or required on a case-by-case basis.

A minimum of 12 months HRT (Hormone Replacement Therapy) completion and physician documented letter(s) verifying the completion for the following procedures:

HRT Letter ALWAYS Required for:

* Vaginoplasty – Penile Inversion & Zero Depth
* Orchiectomy – w/ & w/o Scrotoplasty
* MTF Breast Augmentation – Implant based & Fat Grafting
* Hysterectomy & Salpingo-oophorectomy

HRT Letter SOMETIMES Required for:

* FTM Top Surgery – Double Incision, Keyhole & Nipple-free
(Some insurance policies will require HRT completion, we will advise when applicable.)
* Facial Feminization
* Other Gender Affirming Plastic Surgery Procedures

 

 

The HRT prescribing doctor(s) letter must include ALL of the following:

  1. Patients legal and preferred name, if different
  2. Patients date of birth
  3. Date provider/patient relationship began
  4. Frequency of contact/visits/follow up care
  5. Date hormone therapy began – date initially prescribed and date letter writing doctor prescribed, if different.
  6. State what is being prescribed to patient for hormone therapy
  7. State that patient has a confirmed diagnosis of Gender Dysphoria
  8. State that hormone therapy is specifically for the treatment of Gender Dysphoria
  9. State that the patient has does not have a contraindication to hormone therapy OR state that they do have a contraindication and provide detailed notes on the contraindication
  10. Letter must be physically signed by the treating physician
  11. Letter must be printed on official practice or physicians letterhead

Completed letters should be sent to Dr. Gallagher’s office via any the following methods: 

Fax:  Attention- Dr. Gallagher (317) 968-1371
Email:  AskUs@UniversityGenderAffirmationSurgery.com
Mail:  Attention- Dr. Gallagher, 545 Barnhill Dr. EH 232, Indianapolis, IN 46202

Please visit our website for further information at www.UniversityGenderAffirmationSurgery.com