Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:
Discrimination is Against the Law
Smiley Dental & Orthodontics complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Smiley Dental & Orthodontics does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Smiley Dental & Orthodontics:
If you believe that Smiley Dental & Orthodontics 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: Ruby Reyna, 10901 Garland Rd. Dallas, TX 75218 214-466-1400 ext. 1026 email@example.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Smiley Dental & Orthodontics’ 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.