LIBERTY Dental Nondiscrimination Notice

Nondiscrimination Statement

Discrimination is against the law. LIBERTY Dental Plan (“LIBERTY”) follows State and Federal civil rights laws. LIBERTY does not unlawfully discriminate, exclude people, or treat them differently because of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation.

LIBERTY provides

• Free aids and services to people with disabilities to help them communicate better, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• 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, please contact us between 8 a.m. to 5 p.m (PST) by calling (888) 703-6999. Or, if you cannot hear or speak well, please call (800) 735-2929.

HOW TO FILE A GRIEVANCE

If you believe that LIBERTY has failed to provide these services or unlawfully discriminated in another way on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation, you can file a grievance with LIBERTY’s Civil Rights Coordinator. You can file a grievance by phone, in writing, in person, or electronically:

• By phone: Contact LIBERTY’s Civil Rights Coordinator, Monday through Friday, 8 a.m to 5 p.m (PST) by calling 888-704-9833. Or if you cannot hear or speak well, please call (800) 735-2929.
• In writing: Fill out a complaint form or write a letter and send it to: P.O. Box 26110, Santa Ana, CA 92799
• In person: Visit your doctor’s office or LIBERTY Dental Plan and say you want to file a grievance.
• Electronically: Visit LIBERTY Dental Plan website at https://www.libertydentalplan.com.

OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES

You can also file a civil rights complaint with the California Department of Health Care Services, Office of Civil Rights by phone, in writing, or electronically:

• By phone: Call 916-440-7370. If you cannot speak or hear well, please call 711 (Telecommunications Relay Service).
• In writing: Fill out a complaint form or send a letter to:
  Michele Villados
  Deputy Director, Office of Civil Rights Department of Health Care Services
  Office of Civil Rights
  P.O. Box 997413, MS 0009
  Sacramento, CA 95899-7413
  Complaint forms are available at http://www.dhcs.ca.gov/Pages/Language_Access.aspx.
• Electronically: Send an email to CivilRights@dhcs.ca.gov.

OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

If you believe you have been discriminated against on the basis of race, color, national origin, age, disability or sex, you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by phone, in writing, or electronically:

• By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD 1-800-537-7697.
• In writing: Fill out a complaint form or send a letter to:
  U.S. Department of Health and Human Services
  200 Independence Avenue, SW
  Room 509F, HHH Building
  Washington, D.C. 20201
  Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
• Electronically: Visit the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.