Nondiscrimination Policy

Dr. Black’s Eye Associates complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Dr. Black’s Eye Associates does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

 Language Assistance

Dr. Black’s Eye Associates provides services to people with disabilities to communicate effectively with us, such as:

• 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, or 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 Robert Dienethal, Practice Manager.

If you believe that Dr. Black’s Eye Associates 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 in person, by mail, or over the phone:

Robert Dienethal
302 W. 14th Street, Suite 100A
Jeffersonville, IN 47130
(812) 284-0660

If you need help filing a grievance, Robert Dienethal, Practice Manager, 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/smartscreen/main.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. 2021 1-800-868-1019, (TDD 1-800-537-7697.

Complaint forms are available at http://www.hhs.gov/ocr/filing-with-ocr/index.html

Informing Individuals with Limited English Proficiency of Language Assistance Services

Dr. Black’s Eye Associates complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak a foreign language, assistance services, free of charge, are available to you. Call 1-888-393-2273.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-696-6775 (TTY: 800-537-7697).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-877-696-6775 (TTY：800-537-7697）

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-696-6775 (TTY: 800-537-7697).

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-877-696-6775 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 800-537-7697).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-696-6775 (TTY: 800-537-7697).

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 800-537-7697) رقم .(1-877-696-6775 :والبكم الصم ھ

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-696-6775 (TTY: 800-537-7697) 번으로 전화해 주십시오.

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-696-6775 (телетайп: 800-537-7697).

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-877-696-6775 (ATS: 800-537-7697)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-696-6775 (TTY: 800-537-7697).

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-877-696-6775 (TTY: 800-537-7697).

توجھ: اگر بھ زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما .بگیرید تماس 1-877-696-6775 (TTY: 800-537-7697) با. باشد می ف

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-877-696-6775 (TTY: 800-537-7697).

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-877-696-6775 (መስማት ለተሳናቸው: 800-537-7697).

Section 1557 of the Affordable Care Act Grievance Procedure

It is the policy of Dr. Black’s Eye Associates not to discriminate on the basis of race, color, national origin, sex, age or disability. The Surgery Center has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities.

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for the Practice to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.

Submission of Grievance

Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.

A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.

Investigation

The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of the Practice relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.

The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.

Appeal

The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to the (Chief Executive Officer) within 15 days of receiving the Section 1557 Coordinator’s decision. The (Chief Executive Officer) shall issue a written decision in response to the appeal no later than 30 days after its filing.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is 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, DC 20201.

Bring your complaints first to your doctor and nurses. If you have Medicare, you can file a complaint with your State’s Quality Improvement Organization. Talk to your hospital social worker if you believe you are not ready for discharge from the hospital. Billing complaints should be discussed with the hospital or Medicare carrier.

Accommodations in the Grievance Process

Dr. Black’s Eye Associates will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.

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