Form Fa-001-S - Solicitud De Beneficios (Page 28 of 31) in pdf

NOTICE OF NON-DISCRIMINATION

The Arizona Health Care Cost Containment System (AHCCCS) and the Department of Economic Security

(DES) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, or sex. AHCCCS and DES do not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex. AHCCCS and DES provide free aids and services

to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and

written information in other formats (large print, audio, accessible electronic formats, and other formats).

AHCCCS and DES provide free language services to people whose primary language is not English, such as

qualified interpreters and information written in other languages. If you need these services, contact the Health-

(

e-Arizona Plus Customer Support Center at 1-855-432-7587

TTY: 711). Also, under the Food Stamp Act and

USDA policy, DES is prohibited from discriminating on the basis of religion or political beliefs.

If you believe that AHCCCS or DES 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. You can file a grievance in

person or by mail, fax, or email. Your grievance must be in writing and must be submitted within 180 days of

the date that the person filing the grievance becomes aware of what is believed to be discrimination.

Submit your AHCCCS grievance to: General Counsel, AHCCCS Administration, Office of Administrative

Legal Services, MD 6200, 701 E. Jefferson, Phoenix, AZ 85034 Fax: 602 253 9115 Email:

EqualAccess@azahcccs.gov. You can also file an AHCCCS 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 at U.S. Department of

Health and Human Services; 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C.

20201; or by phone: 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at

Submit your DES discrimination complaint/grievance to: Arizona Department of Economic Security,

Director’s Office, Mail Drop 1111, P. O. Box 6123 Phoenix, Arizona 85005-6123.

DHHS: Write DHHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W.,

Washington, D. C. 20201 or call 202-619-0403 (voice) or 202-619-3257 (TDD).

USDA: You may complete the USDA Program Discrimination Complaint Form, found online at

, or at any USDA office, or call (866) 632-9992 to request

the form. You may also write a letter containing all of the information requested in the form. Send your

completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of

Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or

email at program.intake@usda.gov. You may also call 202-720-5964 (voice and TDD).

FA-001-S (12-17)

AH-1000 (12-17)

Pagína 19

Form Fa-001-S - Solicitud De Beneficios Page 28