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ATTACHMENT 8

Office of Informatics and Analytics VHA Information Access and Privacy Office Privacy Fact Sheet October 2012 Volume 12, No. 04

Transgender Identity Changes

This fact sheet provides guidance to the field on the requirements for transgender changes within the Computerized Patient Record System (CPRS). Any transgender change is an amendment requiring the Veteran or “personal representative” to submit a written request (see Privacy/HIM Fact Sheet, Vol. 09, No. 4 revised March 2012).

Transgender: Transgender is a term used to describe people whose gender identity (sense of themselves as male or female) or gender expression differs from that usually associated with their sex assigned at birth.

Patients will be addressed and referred to based on their self-identified gender. The documented sex in the Computerized Patient Record System (CPRS) should be consistent with the patient’s self-identified gender. In order to modify administrative data (e.g., name and sex) in CPRS, patients must provide official documentation as per current VHA policies.

Typographical errors or misspellings in the name, gender, SSN, or date of birth can be corrected at a facility level. Per VHA Handbook 1907.01: “Administrative correction is the documentation by administrative personnel with the authority to correct information previously captured by or in error.” Only in the event that the Name, Gender or SSN has been changed will a Privacy Act amendment need to be processed. The Privacy Officer’s approval and supporting legal documentation should then be submitted to the HC IdM Team for review and completion of the requested change(s).

In the case of gender reassignment, a written request and one form of supporting documentation is required such as legal documentation (i.e., amended birth certificate or court order), passport or a signed original statement on office letterhead, from a licensed physician. Sexual reassignment surgery is not a prerequisite for amendment of gender.

The licensed physician’s statement must include ALL of the following information:

Your facility Master Veteran Index (MVI) point of contact will send the Privacy Officer’s approval and supporting gender change documentation to the Identity Management Data Quality (IMDQ) Team for official gender changes.

Note: The Privacy Officer does not need to go back and change prior existing documents when approving a transgender change. At the time documentation was written, the information was correct and accurate as provided by the Veteran. Otherwise when the information is changed in the computer based on your amendment approval, any future documentation will have the current gender listed. This needs to be made clear in your response back to the Veteran.

Reference:

VHA Directive 2011-024, Providing Health Care for Transgender and InterSex Veterans VHA Directive 2007-037, Identity Authentication for Health Care Services VHA Directive 2006-036, Data Quality Requirements for Identity Management and Master Patient Index Functions

Privacy Office at a glance VHA personnel should contact the VHA Privacy Office via email through the VHA Privacy Issues mail group for additional questions.

Website: http://vaww.vhaco.va.gov/privacy image1.jpeg image2.png