Affordable Care Act (ACA) Example

Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law

[#Practice Name] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  [#Practice Name] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

            [#Practice Name]:

            • Provides free aids and services to people with disabilities to communicate effectively with us, such as:

                        ○ Qualified sign language interpreters

            ○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

            • Provides free language services to people whose primary language is not English, such as:

                        ○ Qualified interpreters

                        ○ Information written in other languages

            If you need these services, contact [#Name of Civil Rights Coordinator]

If you believe that [#Practice 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: [#Name and Title of Civil Rights Coordinator], [#Mailing Address], [#Telephone number ], [#TTY number—if covered entity has one], [#Fax], [#Email]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, [#Name and Title of Civil Rights 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.

 

ATENCIÓN:  si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.  Llame al 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

 

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-xxx-xxx-xxxx（TTY：1-xxx-xxx-xxxx）。

 

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-xxx-xxx-xxxx（TTY：1-xxx-xxx-xxxx）。

 

주의:  한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.  1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx)번으로 전화해 주십시오.

 

ВНИМАНИЕ:  Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.  Звоните 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx).

 

PAUNAWA:  Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.  Tumawag sa 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

 

УВАГА!  Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки.  Телефонуйте за номером 1-xxx-xxx-xxxx (телетайп:  1-xxx-xxx-xxxx).

 

ប្រយ័ត្ន៖  បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។  ចូរ ទូរស័ព្ទ 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx)។

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-xxx-xxx-xxxx（TTY:1-xxx-xxx-xxxx）まで、お電話にてご連絡ください。

 

ማስታወሻ:  የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-xxx-xxx-xxxx (መስማት ለተሳናቸው: 1-xxx-xxx-xxxx).

 

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama.  Bilbilaa 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

 

ملحوظة:  إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان.  اتصل برقم 1-xxx-xxx-xxxx (رقم هاتف الصم والبكم: 1-xxx-xxx-xxxx).

 

ਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx) 'ਤੇ ਕਾਲ ਕਰੋ।

 

ACHTUNG:  Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.  Rufnummer: 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

 

ໂປດ​ຊາບ: ຖ້າ​ວ່າ ທ່ານ​ເວົ້າ​ພາ​ສາ ລາວ, ການ​ບໍ​ລິ​ການ​ຊ່ວຍ​ເຫຼືອ​ດ້ານ​ພາ​ສາ, ໂດຍບໍ່​ເສັຽ​ຄ່າ, ແມ່ນມີ​ພ້ອມໃຫ້​ທ່ານ. ໂທ​ຣ 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).