Highmark Patient Request For Medical Records Transfer Form Page 2
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3Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and
gender identity. The Claims Administrator/Insurer does not exclude people or treat them differently because
of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender.
Furthermore, the Claims Administrator/Insurer will not deny or limit coverage to any health service based
on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from
the one to which such health service is ordinarily available. The Claims Administrator/Insurer will not deny or
limit coverage for a specific health service related to gender transition if such denial or limitation results in
discriminating against a transgender individual. The Claims Administrator/Insurer:
• 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, 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 the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and
gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222,
Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: .
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights
Coordinator 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/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
.
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