Patient Notice of Rights in Accordance with the ADA Section 504 and ACA Section 1557
We will take reasonable steps to provide free-of-charge language assistance services to people who languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing.
Mark D. Thebaut D.D.S., P.C., d/b/a Tebo Dental and its affiliated practices are dedicated to providing services to patients, companions and visitors in a professional and courteous manner that respects, protects, and promotes the rights of our patients.
Our staff will treat all of our patients, their companions and visitors receiving services with equality in a courteous manner that is free of any discrimination based on age, race, color, creed, ethnicity, religion, nation origin, marital status, sex, sexual orientation, gender identity or expression, disability, veteran or military status, or any other basis prohibited by federal, state, or local law.
Our staff will determine eligibility for and provide services, and other benefits to all patients, companions and visitors in a similar manner, without subjecting any individual to separate or different treatment on the basis of age, race, color, creed, ethnicity, religion, national origin, marital status, sex, sexual orientation, gender identity or expression, disability, veteran or military status, or any other basis prohibited by federal, state, or local law.
Our staff will courteously inform patients, companions and visitors of the availability of and make reasonable accommodations for disabled patients and patients with limited English proficiency consistent with federal and state requirements at no cost to the patient.
Our staff are prohibited from retaliating against any person who opposes, complains about, or reports discrimination, files a complaint, or cooperates in an investigation of discrimination or other proceeding under federal, state, or local anti-discrimination law.
Any person, who believes that he, she or another person has been subjected to discrimination that is not permitted, may file a complaint with the Chief Compliance Coordinator.
Chief Compliance Coordinator RE: ADA Complaint
P.O. BOX 1953
Lilburn, GA 30047
If you feel you have not received proper assistance with your complaint, you may 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 & Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-866-785-6255, 866-785-6255 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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