[Company Name] complies with applicable Federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex. [Company Name] does not exclude or treat people differently because of race, color, national origin, age, disability, or sex.
[Company Name] strives to provide accommodations to patients/customers with disabilities or limited English proficiency to ensure effective communication and access to our services. These accommodations may include, as feasible:
- Providing written information in alternative formats (e.g., large print, audio, accessible electronic formats) upon request
- Offering language assistance services, such as access to qualified interpreters, when possible
The accommodations will depend on the individual’s needs, the notice provided, and the resources available to our [practice/company/organization]. We will do our best to find mutually agreeable solutions within our abilities.
If you anticipate needing accommodations for your [visit/appointment/service], please contact [Contact Name/Title] at the [phone number], [email address], or [office address] provided on the Contact page of this website with as much advance notice as possible so we can discuss your needs and explore potential arrangements.
If you believe that [Company Name] has failed to provide appropriate accommodations or has discriminated based on race, color, national origin, age, disability, or sex, you can file a grievance with [Contact Name/Title] at the [phone number], [email address], or [office address] listed on the Contact page.
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, [Contact Name/Title] and the [Company Name] staff can assist 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 https://eforms.state.gov/Forms/ds4282.PDF