NOTICE OF NON-DISCRIMINATION
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[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.
[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 [PLAN NAME] 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:
Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Mail: U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F, HHH Building
Washington, DC 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone: 1-800-368-1019 (TTY/TDD 800-537-7697)
