Discrimination is Against the Law
AZ Pain Doctors complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. AZ Pain Doctors does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
AZ Pain Doctors:
• 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,
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact Jared Komernicky, Practice Administrator.
If you believe that AZ Pain Doctors 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: Jared Komernicky, Practice Administrator, 21025 N. 8th Way, Ste 110 Phoenix, AZ 85024, Phone 602-795-8700, Fax 602-795-8701, email@example.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,
Jared Komernicky, Practice Administrator 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.
You can schedule an appointment by email or text message. We’ll follow up to confirm a time and date.
firstname.lastname@example.org | 602-536-9494