Appendix A to Part 92 – Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:
Jefferson Dental Clinics complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Jefferson Dental Clinics does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
If you believe that Jefferson Dental Clinics 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: Marti Diaz, Vice President of Human Resources, 3030 LBJ Freeway, Suite 1400, 972.663.5312 (phone), 972.663.5212 (fax),firstname.lastname@example.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Marti Diaz, Vice President of Human Resources, 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:
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Complaint forms are available at http://www.hhs.gov/ocr/filing-with-ocr/index.html.