Non discrimination Statement

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Ballinger Family Dental Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Ballinger Family Dental Care does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Ballinger Family Dental Care:

• 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 believe that Ballinger Family Dental Care 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:

Paul Hopgood, Business Manager,

705 Coliseum Drive Winston Salem, NC 27106

Office: 336-721-7921,

Fax:       336-721-2011

Email:   office@ballingerfamilydental.com.

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Paul Hopgood, Business Manager 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.