Appendix A to Part 92 – Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law.
Thief River Falls Family Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
Thief River Falls Family Dentistry does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
Thief River Falls Family Dentistry:
- 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 Dr. Michael Eickman. If you believe that Thief River Falls Family Dentistry has failed to provide these services or discriminated in another way on the basis of race, floor, national origin, age, disability or sex, you can file a grievance with:
Thief River Falls Family Dentistry
PO Box 655
Thief River Falls, MN 56701
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Dr Michael Eickman is available to help you.
You can also file a civil rights complaint with the US 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:
200 Independence Ave, SW
Room 509F, HHH Building
Washington, DC 20201
1.800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.