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.
[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.
At [name of practice], your health and the health of our staff are of the utmost importance. To ensure your health and the health of our staff, we do follow usual universal precautions in our operatories and office. Additionally, every half hour to an hour we wipe down the waiting room and common spaces with disinfectant.
For the protection of all our patients and staff due the recent outbreak of coronavirus, we are requesting the following:
- If you have an illness or are exhibiting symptoms, we recommend you cancel and reschedule your dental appointment. Some illness and symptoms include:
- a cold or the flu
- fever or nausea
- severe headaches or body aches
- muscle or stomach pain, chest pain or difficulty breathing
- vomiting or diarrhea
- active tuberculosis (TB)
- mumps, measles, chickenpox
- other contagious disease
- Please notify our staff before your appointment if you or someone you are in close contact with have recently traveled to one of the countries with large outbreaks of COVID-19 (ex. China, Italy, Iran, South Korea) or if you have been exposed to someone else who was diagnosed with COVID-19 or who was quarantined as a precaution.
If you are healthy, there’s no need to cancel your regularly scheduled dental appointment.
If you have any questions or concerns, please contact us immediately. The below links provide additional information regarding the coronavirus:
- World Health Organization (WHO): https://www.who.int
- Centers for Disease Control (CDC): https://www.cdc.gov
Our team will continue to monitor the situation and provide updated information when warranted. Thank you for your patronage.