DOH Model Notice

  • Notice also available in Portable Document Format (PDF)

NOTICE OF NON-DISCRIMINATION

[PLAN NAME] complies with Federal civil rights laws. [PLAN NAME] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex (as defined in 45 CFR § 92.101(a)(2)).

[PLAN NAME] provides the following:

  • Free aids and services to people with disabilities to help you communicate with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Free language services to people whose first language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, call [PLAN NAME] at <toll free number>. For TTY/TDD services, call <TTY>.

If you believe that [PLAN NAME] has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with [name and title of Civil Rights Coordinator] by:

  • Mail: [ADDRESS], [CITY], [STATE] [ZIP CODE],
  • Phone: [PHONE NUMBER] (for TTY/TDD services, call <TTY>)
  • Fax: [FAX NUMBER]
  • In person: [ADDRESS], [CITY], [STATE] [ZIP CODE]
  • Email: [EMAIL ADDRESS]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by:

This notice is available at [PLAN NAME]’s website: [PLAN WEBSITE URL].