Transgender Health Services

Transition Surgery Eligibility and Referral Process

Important Note: If your clinic has access to the DPH e-referral system ("LCR"), please submit your referral there. If your clinic does NOT have access, please this form.

Eligibility and Referral Process

PDF version of the Eligibility and Referral Process chart

Para español, haga clic aquí

Policies and Required Documentation for Surgery

Criteria and Summary Requirements for Surgery
Referral Policy and Submission Guidelines
Medical Evaluation
Two Psychosocial Assessments documented via the Genital Surgery Referral Form found below OR in supporting letters written by Mental Health Providers (must be licensed)
- This is the form to guide and document your assessment of patients for genital surgeries: Genital Surgery Form for Mental Health Professionals
- Learn more about the Guidelines for Psychosocial Assessments.
- Read the Executive Summary of the Guidelines.

Patient Education Documentation

Patient Education for Orchiectomy - English | Spanish
Patient Education for Vaginoplasty - English | Spanish
Patient Education for Hysterectomy
Patient Education for Subcutaneous Mastectomy with Male Chest Construction
Patient Education for Metoidioplasty
Patient Education for Phalloplasty
Patient Education for Feminizing Mammoplasty

Helpful Links

Transgender Health Services

Transition Surgery Eligibility and Referral Process

Important Note: If your clinic has access to the DPH e-referral system ("LCR"), please submit your referral there. If your clinic does NOT have access, please this form.

Eligibility and Referral Process

Policies and Required Documentation for Surgery

Patient Education Documentation

Surgery Preparation and Aftercare Instructions for Patients