Healthcare Diversity FGA Form

Healthcare Diversity FGA Form

Purpose: This form collects voluntary demographic and diversity-related information for facility-level FGA reporting and internal quality analyses. Information provided will be treated as protected health information and used only in accordance with privacy and anti-discrimination law. Providing data is voluntary and refusal will not affect the quality of care received.

Patient Information

Date of birth:

Male Female Transgender Non-binary Other:

Emergency Contact

Insurance Information

Medical History (brief)

Diversity and Self-Identification

Race / Ethnicity (check all that apply):

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Hispanic or Latino Not Hispanic or Latino Other:

Sexual orientation: Heterosexual / Straight Gay / Lesbian Bisexual Other:

Disability status: Yes No Prefer not to answer

Veteran status: Veteran Not a veteran Prefer not to answer

Under $25,000 $25,000–$50,000 $50,000–$100,000 Over $100,000 Prefer not to answer

Consent for Use and Disclosure of Demographic Data

I authorize the collection and limited disclosure of the demographic and diversity information I have provided for the purpose of Facility Group Assessment (FGA) reporting, internal quality improvement, compliance monitoring, and aggregated statistical reporting. I understand that identifying health information will be handled in accordance with applicable privacy obligations and only disclosed to third parties in de-identified or aggregate form unless required by law.

I understand that:
- Submission of this information is voluntary and will not affect my access to care or treatment.
- I may revoke this authorization in writing at any time by delivering a signed revocation to the facility's privacy officer; revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.
- This authorization expires on the expiration date below, unless an earlier revocation is submitted.

Yes, I consent No, I decline to provide diversity data

Expires on:

Certifications and Acknowledgements

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I acknowledge that the facility has provided a privacy notice regarding the handling of protected health information and that I may request additional restrictions on the use or disclosure of my information, which the facility will consider in accordance with applicable law.

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