Notice of Nondiscrimination

Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement

Discrimination is Against the Law

Upper Cumberland Rural Health Clinic, PLLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with the scope of sex discrimination described at 45 CFR § 92.101(a)(2)) [optional: (or sex, including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity, and sex stereotypes). Upper Cumberland Rural Health Clinic, PLLC does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

Upper Cumberland Rural Health Clinic, PLLC:

• Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services 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 assistance services to people whose primary language is not English, which may include:
  • Qualified interpreters
  • Information written in other languages

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact Brittany Collins, RN, the Practice Administrator at bcollins@cookevillemed.com.

Filing a Grievance

If you believe that Upper Cumberland Rural Health Clinic, PLLC 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:

Brittany Collins, 225 N Willow Ave, Cookeville, TN 38501, phone 931-528-8899, fax 931-854-9112, and bcollins@cookevillemed.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Brittany Collins is available to help you.

Filing a Civil Rights Complaint

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.

This notice is available on the Upper Cumberland Rural Health Clinic, PLLC website: www.cookevillemed.com