Notice About Nondiscrimination and Accessibility Requirements in Our Office: Appendix A to Part 92—Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement: Discrimination is Against the Law Worthington Foot & Ankle LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Worthington Foot & Ankle does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Worthington Foot & Ankle LLC: 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 need these services, contact Celeste Davis , Office for Civil Rights. If you believe that Worthington Foot & Ankle LLC 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: Celeste Davis,Office for Civil Rights, 233 N Michigan Ave. Suite 240 Chicago, IL.60601 Phone#: (800)368-1019, TDD: (800)537-7697 Fax# 202-619-3818 Email:email@example.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Celeste Davis, Office for Civil Rights] 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.