Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:
Discrimination is Against the Law
DERMATOLOGY ASSOCIATES OF GEORGIA, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
DERMATOLOGY ASSOCIATES OF GEORGIA, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and language interpreters scheduled from an outside source.
Provides free language services to people whose primary language is not English, such as: Qualified interpreters and sign language interpreters for the hearing impaired.
**When you make your appointment please indicate the request for a language interpreter or deaf language interpreter, at the time of confirming the appointment so the proper arrangements may be made.**
If you need these services, contact Debra Mollohan DERMATOLOGY ASSOCIATES of Georgia, LLC’s Civil Rights Coordinator.
If you believe that DERMATOLOGY ASSOCIATES OF GEORGIA, LLC 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: Debra Mollohan, Administrator and Civil Rights Coordinator, 2665 N. Decatur Road, Suite 345, 404-321-4600, ext 1252, TTY number— none available at this time, FAX: 404-393-4393, firstname.lastname@example.org.
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Debra Mollohan, Administrator and 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
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.