Notice of Non-discrimination

NONDISCRIMINATORY POLICY

Urological Associates, PC (UAPC) has agreed to comply with the provisions of the Federal Civil Rights Act
of 1964 and all requirements imposed pursuant thereto to the end that no person shall, on the grounds of
race, color, national origin, ancestry, age, sex, religious creed, or disability, be excluded from participation in,
be denied benefits of, or otherwise be subject to discrimination in the provision of any care or service."

CIVIL RIGHTS COMPLIANCE

UAPC complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability or sex. UAPC does not exclude people or treat them differently because
of race, color, national origin, age, disability or sex.

LANGUAGE ASSISTANCE

UAPC provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreter
• Written information if other formats can be requested and made readily available, other formats may include (large print, audio, accessible electronic formats, other formats)

UAPC 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, or you believe that we have 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:

Patricia Williams, MHCA Administrator – Urological Associates, PC
3319 Spring St.
Davenport, IA 52807
Phone: 563-359-1641
Fax: 563-359-4634
Email: williamsp@urologyqc.com

If you need help filing a grievance, our Administrator 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 as follows:

U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F, HHH Building
Washington, DC 20201
1-800-868-1019; 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Urological Associates PC complies with applicable Federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability or sex.

NOTIFICATION OF ASSISTANCE SERVICES FOR INDIVIDUALS WITH LIMITED ENGLISH PROFICIENCY OF LANGUAGE ATTENTION: If you speak a foreign language, assistance services are available to you, free
of charge, at: 1-724-550-4211. Specific translations for Notice of Nondiscrimination,
Nondiscrimination and Taglines are available at:
http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-724-550-4211.
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 1-724-550-4211.
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
1-724-550-4211.
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-724-550-4211.
Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte
ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: 1-724-550-4211.
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-724-550-4211 번으로 전화해 주십시오.
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-724-550-4211.
ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1-724-550-4211) رقم هاتف
4211-550-724-1 :والبكم الصم.
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-724-550-4211.
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-724-550-4211.
ચુ ના: જો તમેજુ રાતી બોલતા હો, તો િન:ુક ભાષા સહાય સવે ાઓ તમારા માટઉપલધ છે. ફોન કરો
1-724-550-4211.
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń
pod numer 1-724-550-4211.
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele
1-724-550-4211.
យ័ត៖ ើសិនអកនិយ រ, ជំនួយក យមិនគិតឈល
គឺចនសំប់បំអក។ ចូរ ទូរស័ព 1-724-550-4211
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para
1-724-550-4211.

SECTION 1557 OF THE AFFORDABLE CARE ACT, GRIEVANCE PROCEDURE
It is the policy of Urological Associates PC (UAPC) not to discriminate on the basis of race, color,
national origin, sex, age or disability. UAPC 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 CFR part 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. 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
UAPC to retaliate against anyone who opposes discrimination, files a grievance, or participates in the
investigation of a grievance.

SUBMISSION OF GRIEVANCE

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.

INVESTIGATION

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 the Practice 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.

APPEAL

The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to
the (Chief Executive Officer) within 15 days of receiving the Section 1557 Coordinator's decision. The
(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, DC 20201
1-800-868-1019; 1-800-537-7697 (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.

ACCOMMODATIONS IN THE GRIEVANCE PROCESS

UAPC 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.