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Chart #:___
FOR OFFICE USE Outpatient Information
Patient Name:
Last, Date:
First MI(Preferred Name)Gender: __
Family Status:
Birth Date: ___Phone (Home):
(Work): ___Ext: Phone (Cell):
Preferred appointment
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How to fill out gender-affirming enrollment and patient
How to fill out gender-affirming enrollment and patient
01
Obtain the necessary enrollment forms from the healthcare provider or facility.
02
Fill out requested personal information such as name, date of birth, contact information, etc.
03
Specify preferred name and pronouns for gender-affirming care.
04
Provide details about transgender or non-binary identity if applicable.
05
Sign and date the enrollment forms as required.
Who needs gender-affirming enrollment and patient?
01
Individuals who identify as transgender or non-binary and are seeking gender-affirming healthcare services.
02
Patients who wish to receive medical care that respects and affirms their chosen gender identity.
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What is gender-affirming enrollment and patient?
Gender-affirming enrollment and patient refers to the process of ensuring that enrollment and healthcare services cater to the specific needs and identities of transgender and gender non-conforming individuals.
Who is required to file gender-affirming enrollment and patient?
Healthcare providers and entities are required to file gender-affirming enrollment and patient forms.
How to fill out gender-affirming enrollment and patient?
Gender-affirming enrollment and patient forms can be filled out by providing accurate and inclusive information about a patient's gender identity and healthcare needs.
What is the purpose of gender-affirming enrollment and patient?
The purpose of gender-affirming enrollment and patient is to ensure that healthcare services are respectful, affirming, and appropriate for transgender and gender non-conforming individuals.
What information must be reported on gender-affirming enrollment and patient?
Information such as preferred name, pronouns, gender identity, medical history, and healthcare needs must be reported on gender-affirming enrollment and patient forms.
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