Fillable Form Hhs-700 - Civil Rights Discrimination Complaint (Page 5 of 8) in pdf

NOTICE TO COMPLAINANTS AND OTHER

INDIVIDUALS ASKED TO SUPPLY INFORMATION

TO THE OFFICE FOR CIVIL RIGHTS

Privacy Act

The Privacy Act of 1974 (5 U.S.C. § 552a) requires OCR to notify individuals whom it asks to supply

information that:

— OCR is authorized to solicit information under:

(i) Federal laws barring discrimination by recipients of Federal financial assistance on grounds of race,

color, national origin, disability, age, sex, religion, and conscience under programs and activities receiving

Federal financial assistance from the U.S. Department of Health and Human Services (HHS), including,

but not limited to, Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq.), Section 504 of the

Rehabilitation Act of 1973 (29 U.S.C. § 794), the Age Discrimination Act of 1975 (42 U.S.C. § 6101 et

seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681 et seq.), Sections 794 and 855 of

the Public Health Service Act (42 U.S.C. §§ 295m and 296g), Section 1553 of the Affordable Care Act (42

U.S.C. § 18113), the Church Amendments (42 U.S.C. § 300a-7), the Coats-Snowe Amendment (42 U.S.C.

§ 238n) and the Weldon Amendment (e.g., Consolidated Appropriations Act of 2017, Pub. L. 115-31, Div.

H, Tit. V, § 507);

(ii) Titles VI and XVI of the Public Health Service Act (42 U.S.C. §§ 291 et seq. and 300s et seq.) and 42

C.F.R. Part 124, Subpart G (Community Service obligations of Hill- Burton facilities);

(iii) 45 C.F.R. Part 85, as it implements Section 504 of the Rehabilitation Act in programs conducted by

HHS; and

(iv) Title II of the Americans with Disabilities Act (42 U.S.C. § 12131 et seq.) and Department of Justice

regulations at 28 C.F.R. Part 35, which give HHS “designated agency” authority to investigate and resolve

disability discrimination complaints against certain public entities, defined as health and service agencies

of state and local governments, regardless of whether they receive federal financial assistance.

(v) The Standards for the Privacy of Individually Identifiable Health Information (The Privacy Rule) at 45

C.F.R. Part 160 and Subparts A and E of Part 164, which enforce the Health Insurance Portability and

Accountability Act of 1996 (HIPAA) (42 U.S.C. § 1320d-2).

OCR will request information for the purpose of determining and securing compliance with the Federal

laws listed above. Disclosure of this requested information to OCR by individuals who are not recipients

of Federal financial assistance is voluntary; however, even individuals who voluntarily disclose

information are subject to prosecution and penalties under 18 U.S.C. § 1001 for making false statements.

Additionally, although disclosure is voluntary for individuals who are not recipients of Federal financial

assistance, failure to provide OCR with requested information may preclude OCR from making a

compliance determination or enforcing the laws above.

Notice to Complainants and Other Individuals

Page 1 of 2

HHS-700 (10/17) (BACK)

Form Hhs-700 - Civil Rights Discrimination Complaint Page 5