Discrimination 1557 Notice

Discrimination is Against the Law

Blue Ridge Oral and Maxillofacial Surgery

complies with applicable Federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability, or sex.

Blue Ridge Oral and Maxillofacial Surgery

does not exclude people or treat them differently because of race, color, national origin, age,

disability, or sex.

Blue Ridge Oral and Maxillofacial Surgery

• 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)

• 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 appropriate dental office staff member]

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 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.