Appendix A to Part 92—Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement:
Discrimination is Against the Law
Long Beach Internal Medical Group complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Long Beach Internal Medical Group does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Long Beach Internal Medical Group
• 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 Centralized Case Management Operations.
If you believe that Long Beach Internal Medical Group has 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: Centralized Case Management Operations.
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, 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.
How to File a Civil Rights Complaint
Complaint Requirements
Your complaint must:
Be filed in writing by mail, fax, e-mail, or via the OCR Complaint Portal
Name the health care or social service provider involved, and describe the acts or omissions, you believe violated civil rights laws or regulations
Be filed within 180 days of when you knew that the act or omission complained of occurred. OCR may extend the 180-day period if you can show "good cause".
File a Civil Rights Complaint Online
Open the OCR Complaint Portal and select the type of complaint you would like to file.
Complete as much information as possible, including:
Information about you, the complainant
Details of the complaint
Any additional information that might help OCR when reviewing your complaint
You will then need to electronically sign the complaint and complete the consent form. After completing the consent form you will be able to print out a copy of your complaint to keep for your records.
File a Civil Rights Complaint in Writing
File a Complaint Using the Civil Rights Discrimination Complaint Form Package
Open and fill out this pdf. Civil Rights Discrimination Complaint Form Package - PDF in PDF format. You will need Adobe Reader software to fill out the complaint and consent forms.
You may either:
Print and mail the completed complaint and consent forms to:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
Email the completed complaint and consent forms to This email address is being protected from spambots. You need JavaScript enabled to view it. (Please note that communication by unencrypted email presents a risk that personally identifiable information contained in such an email, may be intercepted by unauthorized third parties)
File a Complaint without the Civil Rights Discrimination Complaint Form Package
If you prefer, you may submit a written complaint in your own format by either:
Mail to
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
Email to This email address is being protected from spambots. You need JavaScript enabled to view it.
Be sure to include:
Your name
Full address
Telephone numbers (include area code)
E-mail address (if available)
Name, full address and telephone number of the person, agency or organization you believe discriminated against you
A brief description of what happened, including how, why, and when you believe your (or someone else's) civil rights were violated
Any other relevant information
Your signature and date of complaint
The name of the person on whose behalf you are filing if you are filing a complaint for someone else
You may also include:
Any special accommodations for us to communicate with you about this complaint
Contact information for someone who can help us reach you if we cannot reach you directly
If you have filed your complaint somewhere else and where you’ve filed
If you mail a complaint, be sure to send it to:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
You do not need to sign the complaint and consent forms when you submit them by email because submission by email represents your signature.
Language assistance services for OCR matters are available and provided free of charge. OCR services are accessible to persons with disabilities.