Non Discrimination Notice at Urgent Care & Walk-in Clinic in Ooltewah, TN

Notice and Non-Discrimination Statement

AFC Urgent Care/Family Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AFC Urgent Care/Family Care does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AFC Urgent Care/Family Care:

• 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
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreter services
  • Information written in other languages

If you need these services, please notify clinic staff.

If you believe that AFC Urgent Care/Family Care 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:

Jack Fromm, Compliance Officer

1025 Peerless Crossing NW

Cleveland, TN 37312

(423) 476-5990 (p)

(423) 476-5887 (f)

jfromm@afcurgentcare.com

You can file a grievance in person or by mail, fax, or email. If you need help filing grievances contact: David Farlett, Chief Financial Officer.

David Farlett, Chief Financial Officer

1025 Peerless Crossing NW

Cleveland, TN 37312

(423) 476-5990 (p)

(423) 476-5887 (f)

dfarlett@afcurgentcare.com

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.

Proficiency of Language Assistance Services

ATTENTION (English): If you do not speak English, we are able to provide you language assistance services, free of charge,

please contact Jack Fromm at 423.476.5990 or jfromm@afcurgentcare.com.

ATENCIÓN (Spanish): Si usted no habla Inglés, somos capaces de proporcionarle a usted servicios de asistencia lingüística,

de forma gratuita, por favor, póngase en contacto con Jack Fromm al 423.476-5990 o jfromm@afcurgentcare.com .

注意(Arabic)：あなたが英語を話せない場合、私たちはあなたの言語支援サービスを提供することができる、無

料で、jfromm@afcurgentcare.com のために423.476.5990でジャック・フロムまでご連絡ください。

注意 (Chinese)：如果您不会说英语，我们可以免费为您提供语言协助服务，请联系 Jack Fromm：423.476.5990或,

jfromm@afcurgentcare.com .

Chú ý (Vietnamese): Nếu bạn không nói được tiếng Anh, chúng tôi có thể cung cấp cho bạn các dịch vụ hỗ trợ ngôn ngữ,

miễn phí, xin vui lòng liên hệ với Jack Fromm tại 423.476.5990 hoặc 423.4786.5990, jfromm@afcurgentcare.com .

주의(Korean): 당신이 영어를하지 않을 경우, 우리는 jfromm@afcurgentcare.com에 대한 423.476.5990에서

잭 프롬를하면 언어 지원 서비스를 제공하는 무료, 문의하시기 바랍니다 할 수 있습니다

ATTENTION (French): Si vous ne parlez pas anglais, nous sommes en mesure de vous fournir des services d’assistance linguistique, sans frais, s’il vous plaît contacter Jack Fromm au 423.476.5990 ou jfromm@afcurgentcare.com .

ຄວນລະວັງ (Lao): ຖ້າຫາກວ່າທ່ານບໍ່ສາມາດເວົ້າພາສາອັງກິດ,

ພວກເຮົາມີຄວາມສາມາດສະຫນອງບໍລິການທີ່ຊ່ວຍເຫຼືອພາສາ, ການຟຣີ, ກະລຸນາຕິດຕໍ່ Jack

Fromm ທີ່ 423.476.5990 ຫຼື jfromm@afcurgentcare.com .

注意(Amharic)：あなたが英語を話せない場合、私たちはあなたの言語支援サービスを提供することができる、

無償、423.476.5990または jfromm@afcurgentcare.com でジャック・フロムまでご連絡ください。

ACHTUNG (German): Wenn Sie kein Englisch sprechen, können wir Ihnen kostenlos Sprachunterstützung anbieten,

wenden Sie sich bitte an Jack Fromm unter 423.476.5990 oder jfromm@afcurgentcare.com .

注意(Gujarati)：あなたが英語を話せない場合、私たちはあなたの言語支援サービスを提供することができる、

無料で、jfromm@afcurgentcare.comのために423.476.5990でジャック・フロムまでご連絡ください

注意 (Japanese)：なたが英語を話せない場合、私たちはあなたの言語支援サービスを提供することができる、

無料で、jfromm@afcurgentcare.comのために423.476.5990でジャック・フロムまでご連絡ください

ધ્યાન (Tagalog): તમે ઇંગલિશ વાત ન હોય તો, અમે તમને ભાષા સહાય સેવાઓ પૂરી પાડવા માટે વિના મૂલ્યે, 423.476.5990

અથવા jfromm@afcurgentcare.com પર જોશ બુરીલ સંપર્ક કરો સક્ષમ છે

ध्यान दें(Hindi): आप अंग्रेजी नहीं बोलता, तो हम आपको भाषा सहायता सेवाओं, jfromm@afcurgentcare.com के लिए

423.476.5990 पर जैक फ्रॉम प्रदान नि: शुल्क, कृपया संपर्क करें करने में सक्षम हैं

ВНИМАНИЕ (Russian): Внимание: Если вы не говорите по-английски, так что они Способный эй U Предоставление

языка Assistance услуги, бесплатный планшетный заряд, пожалуйста, свяжитесь с 423.476.5990 для Фромм @

अफ़्चुर्गेन्त्चरॅओम на Джека Фромма

注意 (Persian): あなたが英語を話せない場合、我々は無料で、あなたの言語支援サービスを提供することがで

きます、423.476.5990または jfromm@afcurgentcare.com でジャック・フロムまでご連絡ください。