Home | Member Demographic Survey Member Demographic Survey "*" indicates required fields At CCHP, we continue to strive for improvement in providing our members with personalized and culturally competent health care. The information you provide will help us better understand and improve on providing culturally and linguistically equitable and inclusive services to members and will also help us build an inclusive culture that respects diverse perspectives in all that we do.Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Member Number*Include the leading zero for 6-digitsPhone*Email* Date of Birth* MM slash DD slash YYYY MM/DD/YYYYWhat is your race? (Check all that apply) American Indian/Alaska Native Asian Indian Black or African American Cambodian Chamorro Chinese Filipino Guamanian Hmong Japanese Korean Laotian Native Hawaiian Vietnamese White Other Other race(s) that apply to you*What is your Ethnicity African American American Arab Asian Indian Black Chinese European Filipino Hispanic/Latino Iranian Korean Laotian Latin American Mexican Russian Vietnamese Unknown Decline to state Other Ethnicities that apply to you*Preferred Spoken Language*Please Select OneEnglishSpanishCantoneseMandarinTagalogVietnameseArabicFrenchKoreanRussianGermanHaitian CreoleHindiPortugueseItalianPolishYiddishJapanesePersian (Including Farsi, Dari, and Tajik)BengaliThaiUrduGreekPunjabiArmenianSerbo-Croatian (Including Bosnian, Croatia, Montenegrin, and Serbian)HebrewPreferred Written Language*Please Select OneEnglishSpanishChineseTagalogVietnameseArabicFrenchKoreanRussianGermanHaitian CreoleHindiPortugueseItalianPolishYiddishJapanesePersian (Including Farsi, Dari, and Tajik)BengaliThaiUrduGreekPunjabiArmenianSerbo-Croatian (Including Bosnian, Croatia, Montenegrin, and Serbian)HebrewGender at Birth Male Female Intersex Unknown Decline to State Gender Identity Woman Man Transgender Woman / Trans Feminine Transgender Man / Trans Masculine Non-Binary / Genderqueer / Gender Fluid Two Spirit Decline to State Preferred Pronouns He/Him/His She/Her/Hers They/Them/Theirs Ze/Zir/Zirs No Pronoun Other Decline to State Sexual Orientation Lesbian or Gay or Homosexual Straight or Heterosexual Bisexual Do Not Know Decline to State Terminology Questions & AnswersQ: What is the difference between race and ethnicity? A: Race refers to a group of people you align with based on your physical attributes and genetic features. Ethnicity refers to your cultural heritage and preferences that influence your beliefs, values, diet, religion, language, customs and traditions that you may practice. Q: What is the difference between sexual orientation and gender identity? A: Sexual Orientation refers to who you are emotionally, romantically, and/or sexually attracted to. It is different for everyone. Someone can be attracted to people with one or more than one gender identities.Gender identity refers to your inner sense of being male, female, both, neither, or something else. For some people, their gender identity may not match the gender assigned at birth. Q: What happens if I don’t identify with the categories provided? CCHP understands the limitation of the survey we provide and the variety of identities that people may use to describe themselves. That is why we have provided the “Other” option for each question, a space where you can specify the words that you feel describe you the best.Privacy & Protection of DataCCHP and Balance by CCHP are required to comply with various State and Federal laws to protect, secure, retain, and maintain confidentiality of your sensitive and personal information. These laws include, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Centers for Medicare and Medicaid Services (CMS), and the California Consumer Privacy Act (CCPA). CCHP has put in place policies and procedures to ensure that access to or use of your personal information is secure. Policies and processes include standards on how CCHP manages access to and the utilization of identified race, ethnicity, preferred language, gender identity and sexual orientation information collected for current or prospective health plan members. CCHP discloses its procedures for managing access to and the use of collected race, ethnicity, preferred language, gender identity and sexual information at a minimum, at the time of data collection and on CCHP’s website Compliance Privacy page at CCHPHealthPlan.com/ yourconfidentialmedicalinfo. For questions on these policies, please call the CCHP Compliant Hotline at 415-955-8810 or email to CCHPComplianceDept@cchphealthplan.com.Confirm* I hereby certify that, to the best of my knowledge, the provided information is true and accurate. SignatureToday's Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ Printable CCHP Member Demographic Survey in English Printable Member Demographic Survey in Chinese Printable Member Demographic Survey in Spanish
