Hawthorne Optometry Nondiscrimination Statement

Hawthorne Optometry understands that discrimination is against the law and complies with all applicable Federal and State civil rights laws.

Specifically, we do not discriminate on the basis of race, color, national origin, age, disability or sex. We do not exclude patients or treat them any differently based on any of these factors.
When necessary and free of charge to the patient, Hawthorne Optometry:

• Provides aids and services to patients with disabilities when necessary to effectively communicate with them
• Provides qualified sign language interpreters for hearing impaired patients
• Provides language services to those patients who cannot effectively communicate in English. This may include qualified interpreters or written information.

If you believe Hawthorne Optometry has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you may file a grievance with:
John Maanum, O.D. 13427 Inglewood Ave., Hawthorne, CA 90250
Phone: 310-676-2020 Fax: 310-676-2645 email: hawthorneoptometry@sbcglobal.net

You may file your grievance in person, by mail, fax or email. If you need assistance filing a grievance, John Maanum, O.D. is available to assist you.

You may also file a civil rights complaint with the US Department of Health and Human Services, Office for Civil Rights two ways:

• Electronically through the Office of Civil Rights Complaint Portal:

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

• By mail or phone at:

US Department of Health and Human Services
200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201
1-800-368-1019 1-800-537-7697 (TDD)

Complaint forms are available at:
http://www.hhs.gov/ocr/office/file/index.html

Hawthorne Optometry

Individuals With Limited English Proficiency
Information Regarding Language Assistance Services

ATTENTION: If you speak any of the following languages, language assistance services are available (free of charge) to you upon request.
• Spanish
• Chinese
• Vietnamese
• Tagalog
• Korean
• Armenian
• Persian(Farsi)
• Russian
• Japanese
• Arabic
• Panjabi
• Mon-Khmer, Cambodian
• Hmong
• Hindi
• Thai

Hawthorne Optometry

Non-Discrimination Grievance Procedures

It is the policy of Hawthorne Optometry to not discriminate on the basis of race, color, national origin, sex, age or disability. Hawthorne Optometry has adopted an internal grievance resolution procedure for prompt and equitable resolution of any allegation of discrimination as prohibited by Section 1557 of the Affordable Care Act. These actions may be examined by any patient by contacting Hawthorne Optometry

John Maanum
Hawthorne Optometry 13427 Inglewood Ave. Hawthorne, CA 90250
Phone: 310-676-2020 Fax: 310-676-2645 Email: hawthorneoptometry@sbcglobal.net

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for Hawthorne Optometry to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.
Procedure:

• Grievances must be submitted to the Grievance Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
• A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
• The Grievance Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint.
• The Grievance Coordinator will maintain the files and records of {Practice Name} relating to such grievances. To the extent possible, and in accordance with applicable law, the Grievance Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.
• The Grievance Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.
• The person filing the grievance may appeal the decision of the Grievance Coordinator by writing to Hawthorne Optometry within 15 days of receiving the Grievance Coordinator’s decision. Hawthorne Optometry shall issue a written decision in response to the appeal no later than 30 days after its filing.

Hawthorne Optometry will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is 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 1-800-537-7697 (TDD)