Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:
Discrimination is Against the Law
Jeranek Family Chiropractic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Jeranek Family Chiropractic does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Jeranek Family Chiropractic:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other formats)
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact Dr. Janet Jeranek
If you believe that Jeranek Family Chiropractic 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: Dr. Janet Jeranek. You can file a grievance in person or by mail. If you need help filing a grievance, Dr. Janet Jeranek 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.