Confidential Exchange Of Information Form (Page 2 of 3) in pdf

Nondiscrimination Notice and Access to Communication Services

Optum companies (together, “Optum”) provide services to health plans and other health programs or

activities. Optum does not exclude people or treat them unfairly because of sex, age, race, color, national

origin, or disability.

Free services are available to help you communicate with us and with your health plan. Such as, letters

in other languages, or in other formats such as large print. Or, you can ask for an interpreter. To ask for

help, please call the toll-free number on your member ID card. TTY 711.

If you think you weren’t treated fairly because of your sex, age, race, color, national origin, or disability,

you can send a complaint to:

Optum Civil Rights Coordinator

11000 Optum Circle

Eden Prairie, MN 55344

Fax: 855-351-5495

Email:

If you need help with your complaint, please call the toll-free number on your member ID card. TTY

711. You must send the complaint within 60 days of when you found out about the issue.

You can also file a complaint with the U.S. Dept. of Health and Human services.

Online:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at:

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH

Building, Washington, D.C. 20201

Language Assistance Services & Alternate Formats

This information is available in other formats like large

print. To ask for another format, please call the toll-free

number on your member ID card. TTY 711.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.

Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su

disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文(Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付

費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về

ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다.

귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng

tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.

United Behavioral Health operating under the brand Optum

U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California

BH809_12.6.16

Confidential Exchange Of Information Form Page 2