FACILITY NAME Nondiscrimination Notice
FACILITY NAME complies with applicable Federal civil rights laws and does not discriminate on the basis of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression. FACILITY NAME does not exclude people or treat them differently because of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression. Our health plans are also subject to the section 1557 nondiscrimination requirements and will be operated accordingly.
- Provides free auxiliary aids and services to people with disabilities to communicate effectively with us, such as:
- qualified sign language interpreters, video remote interpreting or other aids for hearing impaired individuals
- written information in multiple formats including large print, audio, accessible electronic formats, or other formats for visually impaired individuals
- Provides free language services to people whose primary language is not English, such as:
- qualified interpreters or a language line
- information written in other languages
If you need these services, contact FACILITY NAME’s ADA Coordinator at FACILITY PHONE.
If you believe that FACILITY NAME has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with:
CITY NAME, STATE NAME ZIP CODE
Phone: FACILITY PHONE
Fax: FACILITY FAX
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, FACILITY NAME’s ADA Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
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