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.
- Put the name you're changing to in the Last and First fields.
- Put Self in the Relationship to Patient field.
- Put your email address in the Email address field.
- Under Patient Name, put your previous name.
- Under Patient's Date of Birth, put your date of birth in the US format (MM/DD/YYYY).
- Sign in the signature field and put the current date under it in the US format.
- 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):
