Member Demographic Survey "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.At Balance, 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. We appreciate you taking 5 minutes to complete this questionnaire. Your information is protected by law and will be saved in your record. We will not disclose any personal information without your written permission. Please read additional information regarding the confidentiality and retention of our data collection.Member ID*Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Phone*Email* Date of Birth* MM slash DD slash YYYY Preferred Written Language*EnglishSpanishChineseTagalogVietnameseArabicFrenchKoreanRussianGermanHaitian CreoleHindiPortugueseItalianPolishYiddishJapanesePersian (Including Farsi, Dari, and Tajik)BengaliThaiUrduGreekPunjabiArmenianSerbo-Croatian (Including Bosnian, Croatia, Montenegrin, and Serbian)HebrewPreferred Spoken Language*EnglishSpanishCantoneseMandarinTagalogVietnameseArabicFrenchKoreanRussianGermanHaitian CreoleHindiPortugueseItalianPolishYiddishJapanesePersian (Including Farsi, Dari, and Tajik)BengaliThaiUrduGreekPunjabiArmenianSerbo-Croatian (Including Bosnian, Croatia, Montenegrin, and Serbian)HebrewWhat is your race? (Check all that apply) American Indian/Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White/Caucasian Other; please specify Unknown Decline to state Other race(s) that apply to you*What is your Ethnicity? (Check all that apply): African American American Arab Asian Indian Black Chinese European Filipino Hispanic/Latino Iranian Korean Laotian Latin American Mexican Russian Vietnamese Other; please specify Unknown Decline to state Other ethnicity or ethnicities that apply to you:What is your assigned sex at birth? Female Male Unknown Decline to State What is your current gender identity? Female Male Transgender Male / Trans Man / Female-To-Male (FTM) Transgender Female / Trans Woman / Male-To-Female (MTF) Genderqueer (neither exclusively male nor female) Decline to State Other What is your sexual orientation? Lesbian or Gay or Homosexual Straight or Heterosexual Bisexual Do Not Know Decline to State Other Thank you for your participation! Your input is valuable to us and will help us enhance our services to meet the diverse needs of Balance members. If you have any questions or concerns, please feel free to reach out to Balance Member Services at 1-888-775-7888 (TTY: 1-877-681-8898), Monday – Friday from 8:00 am to 8:00 pm.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. Today's Date MM slash DD slash YYYY Δ
