_________ complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. _________ does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
If you need these services, contact _________ .
If you believe that _________ 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:
Northeast Pediatric Dental
7122 Rising Sun Avenue
Philadelphia, PA 19111
Phone: (215) 725-8300
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, _________ 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)