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Complete a separate form for each test requested Effective 7/1/2013HEALTH CARE PROVIDER INFORMATIONPATIENT INFORMATION Submitter Code Patient ID Number PATIENT NAME (Last)First MI Suffix Submitter
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American Indian/Alaska Native/Asian refers to individuals who identify as American Indian or Alaska Native alone, Asian alone, or a combination of these races.
Individuals who identify as American Indian or Alaska Native alone, Asian alone, or a combination of these races are required to fill out the American Indian/Alaska Native/Asian section on forms that request this information.
To fill out the American Indian/Alaska Native/Asian section, individuals should check the appropriate boxes based on their racial identity as specified on the form.
The purpose of collecting American Indian/Alaska Native/Asian information is to provide demographic data for statistical analysis and to ensure representation and equity in various sectors.
Individuals need to report their racial identity as American Indian or Alaska Native alone, Asian alone, or a combination of these races.
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