Required in this form if the practice receives federal health funding (for example Medicaid, CHIP or Medicare). [OFFICE TO CONFIRM: attorney to confirm whether the practice is covered]
Notice of nondiscrimination
Americana Family Dental complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex. We do not exclude people or treat them differently because of these things.
We provide, free of charge and in a timely manner:
- Help for people with disabilities to communicate with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats), and reasonable changes to our policies when needed.
- Language help for people whose first language is not English, such as qualified interpreters and information written in other languages.
To ask for these services, tell the front desk or call (407) 850-0133 [OFFICE TO CONFIRM: TTY / Florida Relay 711 line].
If you believe we failed to provide these services or discriminated against you, you can file a grievance with [OFFICE TO CONFIRM: Section 1557 Coordinator — required only if 15+ employees; otherwise the office manager], 2067 Americana Blvd, Orlando, FL 32839, (407) 850-0133, [OFFICE TO CONFIRM: email]. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, online at ocrportal.hhs.gov, by mail at 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, or by phone at 1-800-368-1019 (TDD 1-800-537-7697). Complaint forms: www.hhs.gov/ocr/complaints.
Language assistance — free help in your language
Federal rules ask covered practices to post this notice in English and the 15 languages most often spoken in Florida by people with limited English. Spanish and Haitian Creole come first because they are the most common home languages in our ZIP code after English.
- Tiếng Việt (Vietnamese) — [OFFICE TO CONFIRM: tagline]
- Português (Portuguese) — [OFFICE TO CONFIRM: tagline]
- 中文 (Chinese) — [OFFICE TO CONFIRM: tagline]
- Français (French) — [OFFICE TO CONFIRM: tagline]
- Tagalog — [OFFICE TO CONFIRM: tagline]
- Русский (Russian) — [OFFICE TO CONFIRM: tagline]
- العربية (Arabic) — [OFFICE TO CONFIRM: tagline]
- Italiano (Italian) — [OFFICE TO CONFIRM: tagline]
- Deutsch (German) — [OFFICE TO CONFIRM: tagline]
- 한국어 (Korean) — [OFFICE TO CONFIRM: tagline]
- Polski (Polish) — [OFFICE TO CONFIRM: tagline]
- ગુજરાતી (Gujarati) — [OFFICE TO CONFIRM: tagline]
- ไทย (Thai) — [OFFICE TO CONFIRM: tagline]