Cultural Competency Data Form

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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.

Practitioner Name (Last, First MI and Degree)*: Primary Group NPI*: Gateway Practice Group ID*:

Are you Hispanic/Latino? Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) No, not Hispanic/Latino Race American Indiana or Alaska Native. (An individual having origins in any of the original peoples of North and South America, including Central America, and who maintains a tribal affiliation or community attachment.) Asian. (An individual having origins in any of the peoples of the Far East, Southeast Asia or the Indian Subcontinent, including for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand and Vietnam.) Black or African American. (An individual having origins in any of the Black racial groups of Africa.) Native Hawaiian or Other Pacific Islander. (An individual having origins in any of the original peoples of Hawaii, Guam, Samoa, or Pacific Islands.) White/Caucasian: (An individual having origins in any of the original peoples of Europe, the Middle East or North Africa.)

Language(s) Spoken -Any other languages spoken other than English? Nurses and Office Staff Languages Spoken: Any other languages spoken other than English?
What if any translation services are available in your office?

Are you or a staff member Certified in American Sign Language?* Yes No Have you completed any Cultural Competency Training?* Yes No If Yes, identify course name and date: Course Completed: Date:

Person Attesting to the Form:* Title of Person Completing Attestation:*

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 Provider race and ethnicity will not be published in the Gateway Health provider directory, but will only be shared with Gateway Health members upon request.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.* I ageee and understand