Non Discrimination Notice at Urgent Care & Walk-in Clinic in Gastonia, NC

Notice and Non-Discrimination Statement

AFC Urgent Care/Family Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AFC Urgent Care/Family Care does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AFC Urgent Care/Family 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
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreter services
  • Information written in other languages

If you need these services, please notify clinic staff.

If you believe that AFC Urgent Care/Family 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:

Jack Fromm, Compliance Officer
1025 Peerless Crossing NW Cleveland, TN 37312
Phone: 423.476.5990
Fax: 423.476.5887
Email: jfromm@afcurgentcare.com

David Farlett, Chief Financial Officer
1025 Peerless Crossing NW Cleveland, TN 37312
Phone: 423.476.5990
Fax: 423.476.5887
Email: dfarlett@afcurgentcare.com

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.

Proficiency of Language Assistance Services

ATTENTION (English): If you do not speak English, we are able to provide you language assistance services, free of charge. Please contact:

Name: Jack Fromm
Phone Number: 423.476.5990
Email: jfromm@afcurgentcare.com

ATENCIÓN (Spanish): Si no habla inglés, podemos brindarle servicios de asistencia lingüística de forma gratuita. Póngase en contacto con:

Nombre: Jack Fromm
Número de teléfono: 423.476.5990
Correo electrónico: jfromm@afcurgentcare.com

*(Arabic)

ATTENTION :

انتباه:

If you do not speak English, we are able to provide you language assistance services, free of charge. Please contact:

إذا كنت لا تتحدث الإنجليزية، فيمكننا أن نقدم لك خدمات المساعدة اللغوية مجانًا. يرجى الاتصال بـ

Name: Jack Fromm

اسم: Jack Fromm

Phone Number: 423.476.5990

رقم التليفون
٢٠ ٩ ٩ ٥ ٦ ٧ ٤ ٣

Email: jfromm@afcurgentcare.com

بريد إلكتروني: jfromm@afcurgentcare.com

注意（Chinese)： 如果您不会说英语，我们可以免费为您提供语言协助服务。请联系：

名字: Jack Fromm
电话号码: 423.476.5990 (四二三四七六五九九空)
电 邮: jfromm@afcurgentcare.com

CHÚ Ý (Vietnamese): Nếu bạn không nói được tiếng Anh, chúng tôi có thể cung cấp cho bạn các dịch vụ hỗ trợ ngôn ngữ miễn phí. Vui lòng liên hệ:

Tên: Jack Fromm
Số điện thoại: 423.476.5990 (四二三四七六五九九空)
địa chỉ email: jfromm@afcurgentcare.com

주의(Korean): 영어를 구사하지 못하는 경우 언어 지원 서비스를 무료로 제공할 수 있습니다. 다음 연락처로 연락해 주십시오.

이름: Jack Fromm
전화 번호: 423.476.5990 (사이삼사칠육오구구영)
이메일: jfromm@afcurgentcare.com

ATTENTION (French): Si vous ne parlez pas anglais, nous sommes en mesure de vous fournir des services d’assistance linguistique, gratuitement. Veuillez contacter:

nom: Jack Fromm
numéro de téléphone: 423.476.5990
e-mail: jfromm@afcurgentcare.com

ຄວາມສົນໃຈ (Lao): ຖ້າທ່ານ່˚ບເວົ້າພາສາອັງກິດ,
ພວກເຮົາສາມາດໃຫ້ການ˚ບລິການຊ່ວຍເຫຼື ອທາງດ້ານພາສາໃຫ້ທ່ານໂດຍ່˚ບຕ້ອງເສຍຄ່າໃຊ້ຈ່າຍ. ກະລຸນາຕິດຕ່˚ :

ຊ່ຼື: Jack Fromm
ເບີໂທລະສັບ: 423.476.5990 (໔໒໓໔໗໖໕໙໙໐)
ອີເມວ: jfromm@afcurgentcare.com

ተውሳክ (Amharic) ፦ እንግሊዝኛ ካልተናገርክ በነጻ የቋንቋ እርዳታ አገልግሎት መስጠት እንችላለን። እባክዎን ያነጋግሩ፦

ስም: Jack Fromm
ስልክ ቁጥር: 423.476.5990 (፬፪፫፬፯፮፭፱፱ዜሮ)
ኢሜይል: jfromm@afcurgentcare.com

BEACHTUNG (German): Wenn Sie kein Englisch sprechen, können wir Ihnen kostenlos Sprachunterstützung anbieten. Bitte kontaktieren Sie:

Name: Jack Fromm
Telefonnummer: 423.476.5990
E-Mail: jfromm@afcurgentcare.com

એટેન્શન (Gujarati) : જો તમે અંગ્રેજી ન બોલતા હો, તો અમે તમને વિનામૂલ્યે ભાષાસહકાર સેિાઓ પૂરી પાડી શકીએ છીએ. મહેરબાની કરીને સંપકક કરો:

નામ: Jack Fromm
ફોન નંબર: 423.476.5990 (૪૨૩૪૭૬૫૯૯૦)
ઇમેઇલ: jfromm@afcurgentcare.com

注意 (Japanese): 英語が話せない場合でも、無料で言語支援サービスを提供できます。下記までご連絡ください。

名前: Jack Fromm
電話番号: 423.476.5990 (四二三四七六五九九空)
メール: jfromm@afcurgentcare.com

ध्यान (Hindi): यदि आप अंग्रेज़ी नहkं बोलते हैं, तो हम आपको ननिःशुल्क भाषा सहायता सेवाएँ प्रिान करने में सक्षम हैं। कृपया संपकक करें:

नाम: Jack Fromm
फ़ोन नंबर: 423.476.5990 (૪૨૩૪૭૬૫૯૯૦)
ईमेल: jfromm@afcurgentcare.com

ВНИМАНИЕ (Russian): Если вы не говорите по-английски, мы можем
предоставить вам услуги языковой помощи бесплатно. Пожалуйста, обращайтесь:

имя: Jack Fromm
номер телефона: 423.476.5990
электронная почта: jfromm@afcurgentcare.com

*(Persian):

ATTENTION

توجه

If you do not speak English, we are able to provide you language assistance services, free of charge. Please contact:

اگر انگليسی بلد نيستيد، ما می توانيم خدمات کمک زبان را به صورت رايگان به شما ارائه دهيم. لطفا تماس بگيريد

Name: Jack Fromm

نام: Jack Fromm

Phone Number: 423.476.5990

شماره تلفن: ٢ ٣ ٤ ٧ ٦ ٥ ٩ ٩ ٠

Email: jfromm@afcurgentcare.com

ايميل: jfromm@afcurgentcare.com