Industry initial medical statement used for Empire Life group short- and long-term disability claims.
- Completed by
- Attending physician or other medical provider
- Issued by
- Empire Life
- Format
- Fillable PDF
- Language
- English
Empire Life Gender Affirmation Pre-Authorization Form
Empire Life group plan members must submit this form to obtain pre-authorization before each gender affirmation procedure, and procedures done before the form is completed are not eligible for reimbursement. A specialist trained in gender affirming care confirms the diagnosis, hormone history, requested procedures, provincial coverage and medical necessity, and a secondary confirmation of diagnosis must be attached.
Who completes it
A specialist, either a licensed physician or a qualified medical practitioner approved by Empire Life and trained in gender affirming care, completes Sections 3 and 4. The patient completes Sections 1 and 2, and the specialist must not be related to the employee or patient or be a business associate.
Submitting and payment
- How to submit it
- The completed form is returned by mail to Empire Life Group Health Claims before the procedure, with the secondary confirmation of diagnosis attached.
- Who pays
- The form states that the patient is responsible for any fees related to its completion.
Good to know
- Only patients 18 years of age or older are eligible for this coverage under the Empire Life form.
- Secondary confirmation can be a previous provincial approval for a provincially covered procedure or confirmation from a different specialist with the diagnosis and date.
- Several procedures can go on one form if the same specialist will complete them; the specialist confirms whether they will perform them and the expected date.
- Section 3 asks whether the patient takes hormones, the start date and whether they have been taken continuously since then.
Get the official form
Download the current version from the source each time; forms change without notice.
Gender Affirmation Pre-Authorization Form
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
Who can complete Empire Life's gender affirmation pre-authorization form?
Section 3 must be completed by a specialist: a licensed physician or a qualified medical practitioner approved by Empire Life who is trained in gender affirming care. The specialist cannot be related to the employee or patient, nor be a business associate, and signs Section 4 with their certified specialty.
Can the Empire Life form be submitted after the procedure?
No. The instructions say to submit the form before each procedure to obtain pre-authorization, and that the patient will not be eligible for reimbursement if the form is completed after the procedure has occurred. Multiple procedures can be included if the same specialist completes them.
What if the procedure is covered by the provincial plan?
If the procedure is covered under the patient's provincial healthcare plan, the patient must apply for coverage under that plan. The specialist statement repeats that the patient must provide Empire Life with confirmation of approval or denial from the provincial or territorial plan or program.