Disclosures


Notice of Nondiscrimination - ACA Section 1557

Discrimination is Against the Law

[The Dental Care Center] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. [The Dental Care Center] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

[The Dental Care Center]:

  • 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.


Statement of Nondiscrimination - ACA Section 1557

[The Dental Care Center] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.


Language Assistance Services - English

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Spanish

 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Chinese

 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-xxx-xxx-xxxx(TTY:1-xxx-xxx-xxxx)


Language Assistance Services - Vietnamese

 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Korean

 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx)번으로 전화해 주십시오.


Language Assistance Services - Tagalog – Filipino

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Russian

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx).


Language Assistance Services - Arabic

 ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم -xxx-xxx-xxxx (رقم هاتف الصم والبكم: 1-xxx-xxx-xxxx).


Language Assistance Services - French Creole

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - French

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-xxx-xxx-xxxx (ATS : 1-xxx-xxx-xxxx).


Language Assistance Services - Polish

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Portuguese

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Italian

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - German

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Japanese

 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-xxx-xxx-xxxx(TTY:1-xxx-xxx-xxxx)まで、お電話にてご連絡ください。


Language Assistance Services - Farsi

 توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رایگان برای شما فراهم می باشد. با -xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx) تماس بگیرید.


Language Assistance Services - Hindi

 ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx) पर कॉल करें।


Language Assistance Services - Armenian

ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-xxx-xxx-xxxx (TTY (հեռատիպ)՝ 1-xxx-xxx-xxxx):


Language Assistance Services - Gujarati

 સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Language Assistance Services - Hmong

 LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).


Contact Us

We encourage you to contact us with any questions or comments you may have. Please call our office or use the contact form below.