50165E Medi-Cal/Healthy Kids

NONDISCRIMINATION NOTICE Discrimination is against the law. Santa Clara Family Health Plan (SCFHP) follows Federal civil rights laws. SCFHP does not discriminate, exclude people, or treat them differently because of race, color, national origin, age, disability, or sex. SCFHP provides: Free aids and services to people with disabilities to

help them communicate better, such as: o Qualified sign language interpreters o Written information in other formats (large print,

audio, accessible electronic formats, other formats)

Free language services to people whose primary

language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact SCFHP between 8:30 a.m. and 5:00 p.m., Monday through Friday by calling 1-800-260-2055. Or, if you cannot hear or speak well, please call 1-800-735-2929 or 711.

50165E Medi-Cal/Healthy Kids

HOW TO FILE A GRIEVANCE If you believe that Santa Clara Family Health Plan (SCFHP) 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 SCFHP. You can file a grievance by phone, in writing, in person, or electronically:

By phone: Contact SCFHP between 8:30 a.m. to 5 p.m., Monday through Friday by calling 1-800-260-2055. Or, if you cannot hear or speak well, please call 1-800-735-2929 or 711.

In writing: Fill out a complaint form or write a letter and send it to:

Attn: Appeals and Grievances Department Santa Clara Family Health Plan 210 E. Hacienda Ave Campbell, CA 95008-6617

In person: Visit your doctors office or SCFHP and say you want to file a

grievance.

Electronically: Visit SCFHPs website at www.scfhp.com. OFFICE OF CIVIL RIGHTS You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by phone, in writing, or electronically:

By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call TTY/TDD 1-800-537-7697.

In writing: Fill out a complaint form or send a letter to:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Electronically: Visit the Office for Civil Rights Complaint Portal at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

http://www.scfhp.com/http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

50165S Medi-Cal/Healthy Kids

AVISO DE NO DISCRIMINACIN La discriminacin es contraria a la ley. Santa Clara Family Health Plan (SCFHP) cumple con las leyes federales de derechos civiles. SCFHP no discrimina, no excluye a las personas, ni las trata de forma diferente debido a la raza, el color de la piel, el pas de origen, la edad, una discapacidad o el sexo. SCFHP proporciona lo siguiente: Ayudas y servicios gratuitos a las personas con

discapacidades para ayudarlas a comunicarse mejor; por ejemplo: o intrpretes calificados de lenguaje de seas o informacin escrita en otros formatos (letra

grande, audios, formatos electrnicos accesibles, otros formatos)

Servicios de idioma gratuitos a las personas cuyo idioma primario no sea el ingls; por ejemplo: o intrpretes calificados o informacin escrita en otros idiomas

Si necesita estos servicios, comunquese con SCFHP de 8:30 a.m. a 5 p.m., de lunes a viernes llamando al 1-800-260-2055. O bien, si tiene dificultades auditivas o del habla, llame al 1-800-735-2929 o al 711.

50165S Medi-Cal/Healthy Kids

CMO PRESENTAR UNA QUEJA Si usted considera que Santa Clara Family Health Plan (SCFHP) no ha proporcionado estos servicios o ha discriminado de alguna manera segn la raza, el color de la piel, el pas de origen, la edad, una discapacidad o el sexo, usted puede presentar una queja ante SCFHP. Puede presentar una queja por telfono, por escrito, en persona o de forma electrnica:

Por telfono: Comunquese con SCFHP de 8:30 a.m. a 5 p.m., de lunes a viernes llamando al 1-800-260-2055. O bien, si tiene dificultades auditivas o del habla, llame al 1-800-735-2929 o al 711.

Por escrito: Llene un formulario de quejas o escriba una carta y envela a:

Attn: Appeals and Grievances Department Santa Clara Family Health Plan 210 E. Hacienda Ave Campbell, CA 95008-6617

En persona: Visite el consultorio de su mdico o SCFHP e indique que desea

presentar una queja.

De forma electrnica: Visite el sitio web de SCFHP en www.scfhp.com. OFICINA DE DERECHOS CIVILES Tambin puede presentar una queja de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos (DHHS) de EE. UU. por telfono, por escrito o de forma electrnica:

Por telfono: Llame al 1-800-368-1019. Si tiene dificultades del habla o auditivas, llame al TTY/TDD 1-800-537-7697.

Por escrito: Llene un formulario de quejas o enve una carta a:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Los formularios de quejas estn disponibles en http://www.hhs.gov/ocr/office/file/index.html.

De forma electrnica: Visite el Portal de quejas de la Oficina de Derechos Civiles

en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

http://www.scfhp.com/http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

50165V Medi-Cal/Healthy Kids

THNG BO CHNG PHN BIT I X Phn bit i x l tri vi php lut. Santa Clara Family Health Plan (SCFHP) tun th lut nh v quyn cng dn Lin bang. SCFHP khng phn bit, loi tr hay i x mi ngi mt cch khc bit do chng tc, mu da, ngun gc quc gia, tui tc, tnh trng khuyt tt, hay gii tnh. SCFHP em li: S h tr v dch v min ph cho ngi khuyt tt

gip h trao i thng tin tt hn, nh: o Thng dch vin ngn ng k hiu t tiu chun o Thng tin c vit li di nh dng khc (ch

in ln, m thanh, nh dng in t c th truy cp, cc nh dng khc)

Dch v min ph v ngn ng cho ngi khng s dng Ting Anh l ngn ng chnh, nh: o Thng dch vin t tiu chun o Thng tin c vit ngn ng khc

Nu qu v cn cc dch v ny, hy lin h SCFHP t 8:30 sng n 5:00 chiu, t Th Hai n Th Su bng cch gi n s 1-800-260-2055. Hoc, nu qu v khng th nghe ni tt, vui lng gi n s 1-800-735-2929 hoc 711.

50165V Medi-Cal/Healthy Kids

CCH THC KHIU NI Nu qu v cho rng Santa Clara Family Health Plan (SCFHP) khng cung cp cc dch v ny hoc phn bit i x qu v do chng tc, mu da, ngun gc quc gia, tui tc, tnh trng khuyt tt, hay gii tnh, qu v c th khiu ni cho SCFHP. Qu v c th khiu ni bng cch gi in, vit n, gp trc tip, hoc hnh thc in t:

Qua in thoi: Hy lin h SCFHP t 8:30 sng n 5:00 chiu, t Th Hai n Th Su bng cch gi n s 1-800-260-2055. Hoc, nu qu v khng th nghe ni tt, vui lng gi n s 1-800-735-2929 hoc 711.

Vit n: Hy in thng tin vo mu n khiu ni hoc vit th v gi n a

ch:

Attn: Appeals and Grievances Department Santa Clara Family Health Plan 210 E. Hacienda Ave Campbell, CA 95008-6617

Gp trc tip: Hy n phng khm bc s ca qu v hoc SCFHP v trnh by

vic qu v mun khiu ni.

Hnh thc in t: Hy truy cp trang mng ca SCFHP ti a ch www.scfhp.com.

VN PHNG C TRCH DN QUYN Qu v cng c th khiu ni quyn cng dn vi B Y t v Dch v Dn sinh Hoa K, Vn phng c trch Dn quyn bng cch gi in thoi, vit n, hoc hnh thc in t:

Qua in thoi: Hy gi n s 1-800-368-1019. Nu qu v khng th nghe ni tt, vui lng gi n s TTY/TDD 1-800-537-7697.

Vit n: Hy in thng tin vo mu n khiu ni hoc gi th n:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Mu n khiu ni c th ti v ti http://www.hhs.gov/ocr/office/file/index.html.

Hnh thc in t: Hy truy cp Cng thng tin Vn phng c trch Dn quyn

ti https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.

http://www.scfhp.com/http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

50165C Medi-Cal/Healthy Kids

Santa Clara Family Health Plan (SCFHP) SCFHP

SCFHP o o

o o

8:30 5:00 SCFHP 1-800-260-2055 1-800-735-2929 711

50165C Medi-Cal/Healthy Kids

Santa Clara Family Health Plan (SCFHP) SCFHP

8:30 5:00 SCFHP 1-800-260-2055 1-800-735-2929 711

Attn: Appeals and Grievances Department Santa Clara Family Health Plan 210 E. Hacienda Ave Campbell, CA 95008-6617

SCFHP

SCFHP www.scfhp.com

(U.S. Department of Health and Human Services) (Office for Civil Rights)

1-800-368-1019 TTY/TDD 1-800-537-7697

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.scfhp.com/http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

50165T Medi-Cal/Healthy Kids

PAUNAWA TUNGKOL SA PAGBABAWAL SA DISKRIMINASYON

Labag sa batas ang diskriminasyon. Sumusunod ang Santa Clara Family Health Plan (SCFHP) sa mga Pederal na batas ukol sa mga karapatang sibil. Hindi gawain ng SCFHP na mandiskrimina, magsantabi ng mga tao, o pakitunguhan sila nang iba dahil sa kanilang lahi, kulay ng balat, pinagmulang bansa, edad, kapansanan, o kasarian. Nagbibigay ang SCFHP ng: Mga libreng tulong at serbisyo sa mga taong may

mga kapansanan upang matulungan silang makipag-usap nang mas madali, gaya ng: o Mga kwalipikadong sign language interpreter o M