OMB Number: 0990-0243 Expiration Date: 06/30/2007 Medicare Certification Civil Rights Information Request Form Please return the completed, signed Civil Rights Information Request form and the required attachments with your other Medicare Provider Application Materials. PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT THE FACILITY: a. CMS Medicare Provider Number: ________________________________ b. Name and Address of Facility: __________________________________ ____________________________________________________________ ____________________________________________________________ c. Administrator's Name _________________________________________ d. Contact Person ______________________________________________ (If different from Administrator) e. Telephone _____________________ TDD _________________________ f. E-mail _________________________ FAX ________________________ g. Type of Facility _______________________________________________ (e.g., Home Health Agency, Hospital, Skilled Nursing Facility, etc.) h. Number of employees: _______________ i. Corporate Affiliation __________________________________________ (if the facility is now or will be owned and operated by a corporate chain or multi-site business entity, identify the entity.) j. Reason for Application _________________________________________ (Initial Medicare Certification, change of ownership, etc.) American LegalNet, Inc. www.FormsWorkflow.com PLEASE RETURN THE FOLLOWING MATERIALS WITH THIS FORM. To ensure accuracy, please consult the technical assistance materials (www.hhs.gov/ocr/crclearance.html) in developing your responses. √ No. REQUIRED ATTACHMENTS Two original signed copies of the form HHS-690, Assurance of Compliance 1. (www.hhs.gov/ocr/ps690.pdf). A copy should be kept by your facility. Nondiscrimination Policies and Notices Please see Nondiscrimination Policies and Notices (www.hhs.gov/ocr/nondiscriminpol.html) for the regulations and technical assistance. A copy of your written notice(s) of nondiscrimination, that provide for admission and services 2. without regard to race, color, national origin, disability, or age, as required by Federal law. Generally, an EEO policy is not sufficient to address admission and services. 3. 4. 5. A description of the methods used by your facility to disseminate your nondiscrimination notice(s) or policy. If published, also identify the extent to which and to whom such policies/notices are published (e.g., general public, employees, patients/residents, community organizations, and referral sources) consistent with requirements of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975. Copies of brochures or newspaper articles. If publication is one of the methods used to disseminate the policies/notices, these copies must be attached. A copy of facility admissions policy or policies. Communication with Persons Who Are Limited English Proficient (LEP) Please see Communication with Persons Who Are Limited English Proficient (LEP) (www.hhs.gov/ocr/commune.html) for technical assistance. For information on the obligation to take reasonable steps to provide meaningful access to LEP persons, including guidance on what constitutes vital written materials, and HHS' "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons," available at http://www.hhs.gov/ocr/lep . This guidance is also available at http://www.lep.gov/ , along with other helpful information pertaining to language services for LEP persons. A description (or copy) of procedures used by your facility to effectively communicate with persons who have limited English proficiency, including: 1. How you identify individuals who are LEP and in need of language assistance. 6. 2. How language assistance measures are provided (for both oral and written communication) to persons who are LEP, consistent with Title VI requirements. 3. How LEP persons are informed that language assistance services are available. A list of all vital written materials provided by your facility, and the languages for which they are available. Examples of such materials may include consent and complaint forms; intake forms with the potential for important consequences; written notices of eligibility criteria, rights, denial, 7. loss, or decreases in benefits or services; applications to participate in a recipient's program or activity or to receive recipient benefits or service; and notices advising LEP persons of free language assistance. American LegalNet, Inc. www.FormsWorkflow.com √ No. REQUIRED ATTACHMENTS Auxiliary Aids and Services for Persons with Disabilities Please see Auxiliary Aids and Services for Persons with Disabilities (www.hhs.gov/ocr/auxaids.html) for technical assistance. A description (or copy) of the procedures used to communicate effectively with individuals who are deaf, hearing impaired, blind, visually impaired or who have impaired sensory, manual or speaking skills, including: 1. How you identify such persons and how you determine whether interpreters or other assistive services are needed. 2. Methods of providing interpreter and other services during all hours of operation as 8. necessary for effective communication with such persons. 3. A list of available auxiliary aids and services, and how persons are informed that interpreters or other assistive services are available. 4. The procedures used to communicate with deaf or hearing impaired persons over the telephone, including TTY/TDD or access to your State Relay System, and the telephone number of your TTY/TDD or your State Relay System. Procedures used by your facility to disseminate information to patients/residents and 9. potential patients/residents about the existence and location of services and facilities that are accessible to persons with disabilities. Requirements for Facilities with 15 or More Employees Please see Requirements for Facilities with 15 or More Employees (www.hhs.gov/ocr/reqfacilities.html) for technical assistance. For recipients with 15 or more employees: the name/title and telephone number of the 10. Section 504 coordinator. For recipients with 15 or more employees: A copy or description of your facility's procedure 11. for handling disability discrimination grievances. Age Discrimination Act Requirements Please see Age Discrimination Act Requirements (www.hhs.gov/ocr/agediscrim.html) for technical assistance, and for information on permitted exceptions. A description or copy of any policy (ies) or practice(s) restricting or limiting admissions or services provided by your facility on the basis of age. If such a policy or practice exists, please 12. submit an explanation of any exception/exemption that may apply. In certain narrowly defined circumstances, age restrictions are permitted. After review, an authorized official must sign and date the certification below. Please ensure that complete responses to all information/data requests are provided. Failure to provide the information/data requested may delay your facility's certification for funding. Certification: I certify that the information provided to the Office for Civil Rights is true and correct to the best of my knowledge. Signature of Authorized Official: ________________________________ Title of Authorized Official: __________________________________________ Date: _________________ American LegalNet, Inc. www.FormsWorkflow.com