NOTICE
Notice Informing Individuals About Nondiscrimination and Accessibility Requirements Camanche Chiropractic Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Camanche Chiropractic Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Camanche Chiropractic Center • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters; and o 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: o Qualified interpreters; and o Information written in other languages If you need these services, contact the Section 1557 Coordinator. If you believe that Camanche Chiropractic Center as 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 with: Section 1557 Coordinator 1601 S. Washington, Camanche, Iowa 52730 Phone 1-563-259-1314 Fax 1-563-259-0852 You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 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 http://www.hhs.gov/ocr/office/file/index.html. English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-338-8366. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-338-8366. Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-338-8366。 Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1- 800-338-8366. Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-338-8366. German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-338-8366. كل رفاوتت ةیوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم -8366-338-800-1: ) Arabic 1 مقرب لصتا .ناجملاب مكبلاو مصلا فتاھ -. Laotian: ໂປດຊາບ: ຖ້າວ່ າ ທ່ ານເວົ ້ າພາສາ ລາວ, ການບໍ ິ ລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ, ໂດຍບໍ ່ ເສັ ຽຄ່ າ, ແມ່ ນມີ ພ້ ອມໃຫ້ທ່ ານ. ໂທຣ 1- 800-338-8366. Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-338-8366.번으로 전화해 주십시오. Hindi: ध्यान द󴀀: य󴀀द आप 󴀀हद� बोलतेह 󴀀तो आपके ि◌लए मु फ्त म󴀀 भाषा सहायता सेवाएं उपलब्ध ह।󴀀 1- 800-338-8366. पर कॉल कर󴀀। French: ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-338-8366. Pennsylvania Dutch: Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-338-8366. Thai: เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-800-338-8366. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-338-8366. Karen: ymol.ymo;= erh>uwdRAunD AusdmtCdAusdmtw>rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM. vDRIAud; 1-800-338-8366. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-338-8366.

http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html. Iowa 1 IA Spanish 2 IA Chinese 3 IA Vietnamese 4 IA Serbo-Croatian 5 IA German 6 IA Arabic 7 IA Laotian 8 IA Korean 9 IA Hindi 10 IA French 11 IA Pennsylvanian Dutch 12 IA Thai 13 IA Tagalog 14 IA Karen 15 IA Russian Minnesota 1 MN Spanish 2 MN Hmong 3 MN Cushite 4 MN Vietnamese 5 MN Chinese 6 MN Russian 7 MN Laotian 8 MN Amharic 9 MN Karen 10 MN German 11 MN Mon-Khmer, Cambodian 12 MN Arabic 13 MN French 14 MN Korean 15 MN Tagalog Nebraska 1 NE Spanish 2 NE Vietnamese 3 NE Chinese 4 NE Arabic 5 NE Karen 6 NE French 7 NE Cushite 8 NE German 9 NE Korean 10 NE Nepali 11 NE Russian 12 NE Laotian 13 NE Kurdish 14 NE Persian (Farsi) 15 NE Japanese North Dakota 1 ND Spanish 2 ND German 3 ND Chinese 4 ND Cushite 5 ND Vietnamese 6 ND Bantu 7 ND Arabic 8 ND Swahili 9 ND Russian 10 ND Japanese 11 ND Nepali 12 ND French 13 ND Korean 14 ND Tagalog 15 ND Norwegian South Dakota 1 SD Spanish 2 SD German 3 SD Chinese 4 SD Karen 5 SD Vietnamese 6 SD Nepali 7 SD Serbo-Croatian 8 SD Amharic 9 SD Sudanic 10 SD Tagalog 11 SD Korean 12 SD Russian 13 SD Cushite 14 SD Ukrainian 15 SD French
APPENDIX C NONDISCRIMINATION STATEMENT Camanche Chiropractic Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

APPENDIX D GRIEVANCE PROCEDURE Section 1557 Grievance Procedure It is the policy of Camanche Chiropractic Center not to discriminate on the basis of race, color, national origin, sex, age or disability. Camanche Chiropractic Center has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. § 18116) and its implementing regulations at 45 C.F.R. pt. 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined in the office of: Section 1557 Coordinator 600 9th Avenue North 1-800-338-8366 Fax 1-712-754-3782 who has been designated to coordinate the efforts of Camanche Chiropractic Center to comply with Section 1557. 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 to ret Osceola Community Hospital aliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. Procedure: • Grievances must be submitted to the Section 1557 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 Section 1557 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 Section 1557 Coordinator will maintain the files and records of Camanche Chiropractic Center relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 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 Section 1557 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 Section 1557 Coordinator by writing to the Administrator/Chief Executive Officer within 15 days of receiving the Section 1557 Coordinator’s decision. The Administrator/Chief Executive Officer shall issue a written decision in response to the appeal no later than 30 days after its filing. 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 1-800-868-1019 800-537-7697 (TDD) Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. Such complaints must be filed within 180 days of the date of the alleged discrimination. Camanche Chiropractic Center 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.