Sample Physician’s Letter for Passport or Social Security Gender Marker Change

To change name and gender marker on your passport or Social Security record, you need a certified name change order, certified birth certificate, a physician’s letter, and a photo ID. The letter must be written by a medical doctor; a general practitioner, endocrinologist, or surgeon. It can NOT be written by a life coach, religious authority, social worker, or therapist.

(ON PHYSICIAN LETTERHEAD)

I, Physician’s Full Name, Physician’s medical license or certificate number, Issuing U.S. State/Foreign Country of medical license/certificate, am the physician of Name of Patient, with whom I have a doctor/patient relationship and whom I have treated (or with whom I have a doctor/patient relationship and whose medical history I have reviewed and evaluated).

Name of Patient has had APPROPRIATE CLINICAL TREATMENT FOR GENDER TRANSITION to (specify new gender male or female).

I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.

Signature of Physician
Typed Name
Date