Equality Health Alliance Provider Application Please enable JavaScript in your browser to complete this form.Provider Name *Practice Name *Practice Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePractice Phone *Practice Website / URL *Email *Please indicate the categories which in which you want to be listed (check all that apply) *Addiction Medicine/ServicesAllergyCardiologyChiropracticDentistryDermatologyDialysisDoulaEndocrinologyFamily MedicineGastroenterologyGeneticsGeriatricsGenycologyHematologyHIV MedicineHolistic MedicineHospice & Palliative CareImmunologyInfectious DiseaseInternal MedicineLactation ConsultantMassage TherapyMedical MarijuanaMental HealthMidwifeNephrologyNeurologyNutritionObstetricsOccupational TherapyOncologyOpthamologyOptometryOrthopedicsOsteopathic MedicineOtolaryngologyPain ManagementPediatricsPEP ServicesPharmacyPhysical TherapyPlastic SurgeryPodiatryPrEP ServicesPrimary CarePsychiatryPsychologyPulmonologyRadiologyRepro Health/Family PlanningRheumatologySleep MedicineSpeech PathologySports MedicineSober LivingSTI TestingSTI TreatmentSurgeryTherapy & CounselingTransgender CareUrgent CareUrologyWould you like to list any special services not listed?Would you like to include a personal statement?Do you include a place for patients to indicate their sexual orientation or whom they have sex with (gay, bisexual, MSM, WSW, etc.) when you gather health information on medical forms, during exams, etc.? *YesNoInterested in implementing this practiceIn addition to sex, do you include LGBTQ affirming options for gender identity such as trans, gender non-conforming, agender, etc.? *YesNoInterested in implementing this practiceRegardless of forms, is it the policy of the facility to routinely ask patients/clients for their chosen name and pronoun? *YesNoInterested in implementing this practiceHas your staff completed an LGBTQ Best Practices training and/or training focused on working with the LGBTQ community? *YesNoInterested in implementing this practiceIf yes, what organization provided the training and when?My non-discrimination policy includes:Sexual OrientationGender IdentityRacial/Ethnic IdentityDisabilityMy office space:Is wheelchair accessibleHas gender-inclusive bathroomsMy practice currently serves patients/clients who identify as:GayLesbianBisexual/PansexualTransgender/Gender Non-ConformingOtherDoes your practice care for youth patients (18 and under)? *YesNoIf yes: When caring for youth patients, my practice...Keeps patient sexuality and gender identity confidentialConfidentially refers youth to LGBTQ+ servicesUnderstands possible safety issues for LGBTQ+ youthMy practice accepts these insurance plans: *AetnaBlue Cross Blue Shield of OklahomaCommunity CareHealthChoiceMedicare/MedicaidUnitedHealthCareOtherI am: *Licensed in OKAccepting new patientsProviding sliding scale payment options for those without insuranceIf you are not licensed in Oklahoma, what state are you licensed?Languages spoken in your practice (besides English):Submit
