1557 NOTICE  Non Discrimination Policy

This must be posted in your office for all patients to see.  I suggest you attach a copy to the Notice of Privacy Practices.  Other languages are available if needed please let me know.

If you have more than 15 employees you must have written policies and procedures, as well as, a designated official.

These are samples and may be edited.  (You are required to assist patients request for accommodations for disabilities.)

SAMPLE English version download.doc

SAMPLE Spanish version download.doc


Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:

Discrimination is Against the Law

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

            [Name of covered entity]:

            • 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 [Name of covered entity] 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.


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