.Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination
and Accessibility Requirements and Sample Nondiscrimination Statement:
Discrimination is Against the Law
[Name of covered entity] complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Coastal Dermatology, Inc does not exclude people or treat them differently because of race, color, national origin,
age, disability, or sex.
Coastal Dermatology, Inc:
• 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
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact State of Georgia ACA coordinator's office.
If you believe that Coastal Dermatology, Inc 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: State of Georgia ACA coordinator's office, 270 Washington St. 2nd floor, Suite 2140 Atlanta, GA 30334-9007 (404) 657-9993 Fax (404) 463.5650, Group.GeorgiaADA@gsfic.ga.gov. 
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, State of Georgia ADA coordinator's offfice 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. 

Appendix B to Part 92—Sample Tagline Informing Individuals With Limited English
Proficiency of Language Assistance Services
ATTENTION: If you speak [insert language], language assistance services, free of charge, are
available to you. Call 1-800-726-9891 (Http://Alborsalnet.Com/Tnt/. 
1 Spanish
2 Vietnamese 
3 Korean 
4 Chinese 
5 Gujarati 
6 French 
7 Amharic
8 Hindi 
9 French Creole
10 Russian 
11 Arabic 
12 Portuguese 
13 Persian 
14 German 
15 Japanese

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