Gender affirmation form
Have coverage through your employer or plan sponsor? You’re in the right place.
If you bought coverage through your advisor, use our personal insurance forms instead.
Use this form to request approval for gender affirmation coverage.
Step 1: Complete a form.
Download the form and print it, or fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser) and save. Complete the plan member section.
Use this form to request approval for gender affirmation coverage. You'll need your healthcare provider to fill in some sections.
Step 2: Ask your healthcare provider to complete the physician information section.
Step 3: Submit your request for approval.
You’ll find instructions on how to submit your claim on the form itself.