Non-Discrimination Notice

Nondiscrimination Notice

[Practice Name — set in Compliance Settings] complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

This notice is provided pursuant to Section 1557 of the Affordable Care Act (ACA), 45 CFR Part 92.

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Accessibility and Language Assistance

We are committed to providing equal access to all patients. Upon request, we will make reasonable efforts to provide appropriate auxiliary aids and communication assistance for patients with disabilities, and language assistance services for patients whose primary language is not English. To request assistance, please contact our office prior to your appointment.

If you need assistance, contact us at:

• Practice: [Practice Name — set in Compliance Settings]
• Phone: [Practice Phone — set in Compliance Settings]
• Address: [Practice Address — set in Compliance Settings]

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How to File a Grievance

If you believe that we have 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 us in person, by mail, or by phone. If you need help filing a grievance, we are available to help you.

How to File a Civil Rights Complaint

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, 1-800-537-7697 (TDD)

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.