Cultural Competency Data Form

Cultural Competency Data Form

By providing your race, ethnicity, language and cultural competency training data, you allow Gateway Health to better connect members to the appropriate practitioners, deliver more effective provider-patient communication and improve a patients’ health, wellness and safety.

Please complete the form below.

Are you Hispanic/Latino? Race
Are you or a staff member Certified in American Sign Language?* Have you completed any Cultural Competency Training?*
I do herby attest that the above information is accurate. Provider race and ethnicity will not be published in the Gateway Health provider directory, but will only be shared with Gateway Health members upon request. Cultural Competency training and languages spoken may be published in the Gateway Health Provider Directory.*

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