Children's Hospital Los Angeles

Notice of Patient Demographic Change

Important: Make sure your insurance is updated before doing this if you intend to visit CHLA again, because insurance will decline any procedures billed under the wrong name or legal sex.
This procedure assumes you're changing your legal name, preferred name, legal sex, preferred gender, pronouns, and address. Feel free to modify it as needed.
 

This form (English/Arabic/Armenian/Farsi/Korean/Spanish) is used to update your medical records at CHLA to match a new legal or preferred name, pronouns, gender, and/or legal sex.

  1. Put the name you're changing to in the Last and First fields.
  2. Put Self in the Relationship to Patient field.
  3. Put your email address in the Email address field.
  4. Under Patient Name, put your previous name.
  5. Under Patient's Date of Birth, put your date of birth in the US format (MM/DD/YYYY).
  6. Sign in the signature field and put the current date under it in the US format.
  7. In the Information to Update table
    • Under Legal Name, put your previous name in the Previous column and the name you're changing to in the New column
    • Under Name Used, do the same thing as Legal Name
    • Under Legal Sex, select your AGAB in the Previous column and the gender on your form of ID in the New field.
    • Under Gender, select your AGAB in the Previous column and your preferred gender in New. You may choose either the Transgender variants or the regular ones, depending on how you'd like your gender reflected in your chart.
    • Under Pronouns, select your previous pronouns in the Previous column and your new pronouns in the New column. You may also use neopronouns by selecting the Not Listed field and writing your pronouns on the provided line.

Example

Here's what your form should look like once it's finished (Everything I added is in red for emphasis. Use black when you're filling your form out):

chla-demo-change-1.png

chla-demo-change-2.png

Sending the Request

To send your request to CHLA, attach your filled out Notice of Patient Demographic Change form, a form of ID (passport, driver's license, ID card, etc.), and a non-certified copy of your name/gender change court order to an email and send it to himrequest@chla.usc.edu.

My request took three days from submission to be processed, and I received an email telling me the change is complete.

Obtaining Your Medical Records at CHLA

The easiest way to obtain your medical records at Children's Hospital Los Angeles is using the form at this page. The cost for obtaining personal records is free. Note that obtaining records for other purposes may cost money and if your request results in more than 40 pages, it will be mailed to you on a CD.

CHLA took 30 days to process my request and send me an email with the results. The email will have a link to outlook where you can download your records. The password to the PDF file will be your date of birth in MMDDYYYY format.

Unfortunately, only the headers and new documents you generate will have any info you've changed. Pre-existing documents will still contain old info. Feel free to use find and replace in LibreOffice Draw to take care of that :3