Medical Renewal Form Page 9

Case name:

Case number:

Date of request:

Our discrimination policy

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not

discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat

anyone differently because of age, race, color, national origin, gender, religion, political beliefs,

disability or sexual orientation.

You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons.

To file a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238

(TTY 711) or write to their office at:

Governor’s Advocacy Office

500 Summer Street NE, E17

Salem, OR 97301

Fax: 503-378-6532

Email: DHS.info@state.or.us

“Equal opportunity is the law!”

Need help?

Please call your worker. The phone number is at the top of the first page.

Page 9

OHA 0945 (06/12)

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