Nondiscrimination Notice
[PRACTICE LEGAL NAME / DBA] complies with applicable federal civil rights laws and does not exclude people, deny benefits, or treat people less favorably because of race, color, national origin—including limited English proficiency and primary language—age, disability, or sex, consistent with the scope of currently enforceable law. Additional protections may apply under state or local law.
Free Accessibility and Communication Services
When needed to provide equal access and effective communication, the practice provides reasonable modifications and appropriate auxiliary aids and services in a timely manner and free of charge. These may include:
- Qualified sign language interpreters and other qualified interpreters.
- Written information in accessible formats, including large print, accessible electronic formats, audio, or other formats.
- Reasonable modifications for individuals with disabilities.
Free Language Assistance Services
For people whose primary language is not English, free language assistance may include qualified interpreters and translated written information. The practice will not require a patient to provide or pay for an interpreter when the practice is legally required to provide one.
Request Assistance
| Civil Rights Contact | [CIVIL RIGHTS CONTACT] |
|---|---|
| Telephone | [CIVIL RIGHTS PHONE] |
| [CIVIL RIGHTS EMAIL] | |
| Mailing Address | [MAILING ADDRESS] |
File a Grievance
If you believe the practice failed to provide these services or discriminated on a prohibited basis, you may file a grievance in person or by mail or email using the contact information above. The Civil Rights Contact is available to help you submit a grievance. Filing a grievance will not affect access to care or result in retaliation.
File a Federal Civil Rights Complaint
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
- Electronically through the OCR Complaint Portal.
- By mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201.
- By telephone: 1-800-368-1019 or TDD 1-800-537-7697.