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Process & Fees


  1. Your first step would be to schedule a consultation regarding your intended procedure.
  2. You will be emailed a surgery date approximately four to six weeks after your consultation which will include your pre and post-operative appointment dates.
  3. If using insurance, we will begin the authorization process within two to three months prior to your surgery date.
  4. We need all required support letters before we can initiate the authorization process (letter guidelines are below). These are required within one year of your surgery date, but no later than nine months prior to your surgery date.
  5. We will notify you if any issues arise and of the determination that we receive from your insurance company. You should also receive an authorization letter from your insurance company in the mail at the same time as our office.
  6. A comprehensive Surgery Confirmation Packet will be sent to you via email within 30 days prior to your surgery date, including detailed pre and post-operative care instructions.
  7. If you are paying out of pocket, your balance will be due no later than 30 days prior to your surgery date.


$25 Physician Declaration Form Fee

$35 Notarized Physician Declaration Form Fee

$500 Surgery Deposit (Out-of-Network Insurance and Self-Pay Patients Only)

If you are paying out of pocket, a self-pay quote will be provided to you after your consultation. The surgery deposit is collected at your consultation if you decide to move forward with scheduling.

In the event that we are unable to obtain an authorization prior to your surgery, you would have the option to pay out of pocket ahead of time or to reschedule your surgery date.

The surgeon’s fee will become due upfront prior to your surgery date if we are out-of-network with your insurance policy and we are unable to obtain an in-network exception and/or single case agreement for your surgery. We will then submit a claim to your insurance company and reimburse you what/if they pay minus your deductible and out-of-pocket maximum amounts.


Your insurance company requires letters of support from licensed mental health professionals and/or a hormone provider in order to approve coverage for your surgery. Our office requires these letters on file NO LATER OR SOONER THAN 1 YEAR PRIOR TO YOUR SURGERY DATE in order to allow enough time to review and request any revisions that may be necessary. If revisions are needed, the revised letters should be completed as soon as possible or by the deadline given. Please note that all letters must be signed by the provider with their license number and printed on their letterhead. The letters cannot be written by an intern, even if they are co-signed by their supervisor.

The letters can be faxed to (415)-461-3233, emailed to letters@brownsteincrane.com, or mailed to our office (Please consider having the letter faxed or emailed if they are needed by our office urgently).

Below are the letter requirements pertaining to each procedure and a guideline of the criteria that must be met for each letter:

FTM & Gender Non-Conforming Top Surgery, Breast Augmentation, & Facial Feminization Surgery:

  • Letter from a licensed mental health specialist — (ie: LCSW, MFT, LMFT, CSW, Ph.D., Psy.D., etc.)

FTM, MTF, & Gender Non-Conforming Bottom Surgery:

  • Letters from 2 different licensed mental health specialists —
  1. 1 letter should be from a provider who has only had an evaluative role
  2. We recommend that at least one of the letters is from a provider with a doctorate level degree (ie: Ph.D., Psy.D., etc)
  • Letter from your hormone provider


 The mental health provider letter(s) must include:

  • Patient’s legal and preferred name
  • Patient’s date of birth
  • Date provider/patient relationship began and the frequency of contact
  • A statement that the patient has been diagnosed with persistent, well-documented gender dysphoria/gender identity disorder and exhibits all of the following:
  1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
  2. The transgender identity has been present persistently for at least two years; and
  • The disorder is not a symptom of another mental health disorder; and
  1. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Documentation that the patient has completed a minimum of 12 continuous months of living in a gender role that is congruent with their gender identity, across a wide range of life experience and events that may occur throughout the year
  • The patient has undergone a minimum of 12 continuous months of hormone replacement therapy. (RECOMMENDED FOR BOTTOM SURGERY & BREAST AUGMENTATION ONLY)
  • A statement that the patient has the capacity to make fully informed decisions and to consent for treatment
  • That the patient is able to comply with long-term follow-up requirements and post-operative expectations have been addressed
  • If the patient has significant medical or mental health issues present, they must be reasonably well controlled
  • Any substance use (ie: marijuana, alcohol, etc.) is well controlled for at least 6 months prior to the patient’s surgical date
  • The provider must state their experience with treating patients diagnosed with gender dysphoria

The hormone provider letter must include:

  • Patient’s legal and preferred name
  • Patient’s date of birth
  • Date provider/patient relationship began and the frequency of contact
  • Date hormone therapy began and the frequency of treatment
  • That the patient has undergone a minimum of 12 continuous months of hormone replacement therapy
  • If the patient has a contraindication to hormone therapy, please have the provider note this

*Please note that WPATH Standards of Care states that patients should be the age of majority (18 years of age in the US) for bottom surgery coverage, and it is very uncommon for minor to have this procedure approved