Appendix A to Part 92 – Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:
Discrimination is Against the Law
JDC Healthcare Management, LLC, d/b/a Jefferson Dental & Orthodontics and The Smile Center 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 & Orthodontics does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Jefferson Dental & Orthodontics/The Smile Center:
- 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 Cathy Gainey, VP, Human Resources at 972-663-5313 or email@example.com.
If you believe that Jefferson Dental & Orthodontics/The Smile Center 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 Cathy Gainey, VP, Human Resources, 3030 LBJ Freeway, Suite 1700, Dallas, TX 75234 972-663-5313 (phone), firstname.lastname@example.org (email). If you need help filing a grievance, Cathy Gainey, VP, 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/smartscreen/main.jsf, or by mail or phone at:
U.S. Department of Health & Human Services – Office for Civil Rights
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://www.hhs.gov/ocr/filing-with-ocr/index.html.