Referral of a patient to Ontario Health atHome for home and community care services.
- Completed by
- Referring physician, NP or other provider
- Issued by
- Ontario Health atHome
- Format
- Language
- English
OHIP Form 5041-77E: Prior Approval for SRS Funding
Gender-affirming surgery, which the form calls sex-reassignment surgery, is insured by OHIP only with prior authorization from the Ministry of Health, and providers request it with this form. It covers in-province, out-of-province and out-of-country surgery, including genital, chest, hysterectomy and orchidectomy procedures and complication repairs. Supporting assessments must accompany it, and the ministry notifies the referring provider and the patient by letter.
Who completes it
An attending physician or nurse practitioner completes and signs the form; for out-of-country surgery, Section 6 (treatment availability) must be completed by a practising Ontario physician. Supporting assessments come from providers trained under the WPATH Standards of Care: physicians, nurse practitioners, registered nurses, registered psychologists or registered social workers.
Submitting and payment
- How to submit it
- Fax the completed form with the supporting assessments to the ministry's SRS Program, using the number printed on the form; incomplete or illegible forms are returned.
- Who pays
- No provider fee is listed on the form; once prior authorization is granted, the approved surgery is an insured OHIP service.
Good to know
- Genital surgery, hysterectomy, salpingo-oophorectomy and orchidectomy need two assessments: one from a physician or nurse practitioner, and one from a different physician, nurse practitioner, registered nurse, psychologist or social worker.
- Assessors confirm persistent gender dysphoria and 12 continuous months of hormone therapy unless contraindicated; external genital surgery also needs 12 continuous months living in a gender role congruent with identity.
- Chest surgery needs one assessment from an Ontario physician or nurse practitioner; augmentation mammoplasty also requires 12 months of hormone therapy without breast enlargement unless hormones are contraindicated.
- Assessors must be able to document their gender dysphoria training if the ministry asks, and the submitting physician or nurse practitioner may also complete one of the assessments.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for Prior Approval for Funding of Sex-Reassignment Surgery
Demande d'approbation préalable du remboursement d'un changement chirurgical de sexe
Fill it with Vero
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
Who can complete a supporting assessment for OHIP-funded gender-affirming surgery?
A physician, nurse practitioner, registered nurse, registered psychologist or registered social worker trained in assessing and treating gender dysphoria under the WPATH Standards of Care in place at the time. A registered social worker must hold a master's degree in social work and current registration with the Ontario College of Social Workers and Social Service Workers.
Does out-of-country surgery need extra steps?
Yes. Under subsection 28.4(7) of Regulation 552, Section 6 must be completed by a practising Ontario physician. It asks whether the treatment is generally accepted and performed in Ontario, whether delay would cause death or irreversible tissue damage, the expected wait in Ontario, and which physicians were contacted.
Is surgery for a post-surgical complication covered?
Additional surgery needed because of complications causing significant physical symptoms or functional impairment is insured when prior authorization is obtained. The provider ticks Post-Surgical Complication on this same form and explains the proposed procedure and the nature of the complication, including the symptoms or impairment.