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Notice of Nondiscrimination

Discrimination is against the law.

Revive Chiropractic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with the scope of sex discrimination described at 45 CFR § 92.101(a)(2)). Revive Chiropractic does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

Revive Chiropractic:

  • Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services 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 assistance services to people whose primary language is not English, which may include:
    • Qualified interpreters
    • Information written in other languages

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact Hailey Vedvik, Office Manager at 608-855-9698.

If you believe that Revive Chiropractic 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:

Hailey Vedvik, Office Manager

Revive Chiropractic, 3151 Fish Hatchery Rd, Fitchburg, WI 53713

Phone: 608-855-9698

Email: drmadison@revivechirocare.com

Please don't email health details. Call us or use the patient portal instead.

You can file a grievance in person or by mail, phone, or email. If you need help filing a grievance, the contact above 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, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue SW, Room 509F, HHH Building

Washington, DC 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at hhs.gov/ocr/office/file.

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

English wording is the HHS OCR sample notice (45 CFR 92.11). Each translation must be the official HHS OCR translated sample notice for that language; we do not machine-translate.

English

ATTENTION: If you speak English, free language assistance services are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 608-855-9698 (TTY: 711) or speak to your provider.

Spanish (Español)

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. También están disponibles de forma gratuita ayuda y servicios auxiliares apropiados para proporcionar información en formatos accesibles. Llame al 608-855-9698 (TTY: 711) o hable con su proveedor.

Hmong (Hmoob)

LUS CEEV TSHWJ XEEB: Yog hais tias koj hais Lus Hmoob muaj cov kev pab cuam txhais lus pub dawb rau koj. Cov kev pab thiab cov kev pab cuam ntxiv uas tsim nyog txhawm rau muab lus qhia paub ua cov hom ntaub ntawv uas tuaj yeem nkag cuag tau rau los kuj yeej tseem muaj pab dawb tsis xam tus nqi dab tsi ib yam nkaus. Hu rau 608-855-9698 (TTY: 711) los sis sib tham nrog koj tus kws muab kev saib xyuas kho mob.

Chinese (中文)

注意:如果您说中文,我们将免费为您提供语言协助服务。我们还免费提供适当的辅助工具和服务,以无障碍格式提供信息。致电 608-855-9698(文本电话:711)或咨询您的服务提供商。

German (Deutsch)

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlose Sprachassistenzdienste zur Verfügung. Entsprechende Hilfsmittel und Dienste zur Bereitstellung von Informationen in barrierefreien Formaten stehen ebenfalls kostenlos zur Verfügung. Rufen Sie 608-855-9698 (TTY: 711) an oder sprechen Sie mit Ihrem Provider.

Arabic (العربية)

تنبيه: إذا كنت تتحدث اللغة العربية، فستتوفر لك خدمات المساعدة اللغوية المجانية. كما تتوفر وسائل مساعدة وخدمات مناسبة لتوفير المعلومات بتنسيقات يمكن الوصول إليها مجانا. اتصل على الرقم 608-855-9698 (TTY: 711) أو تحدث إلى مقدم الخدمة.

Russian (Русский)

ВНИМАНИЕ: Если вы говорите на русский, вам доступны бесплатные услуги языковой поддержки. Соответствующие вспомогательные средства и услуги по предоставлению информации в доступных форматах также предоставляются бесплатно. Позвоните по телефону 608-855-9698 (TTY: 711) или обратитесь к своему поставщику услуг.

Korean (한국어)

주의: 한국어를 사용하시는 경우 무료 언어 지원 서비스를 이용하실 수 있습니다. 이용 가능한 형식으로 정보를 제공하는 적절한 보조 기구 및 서비스도 무료로 제공됩니다. 608-855-9698(TTY: 711)번으로 전화하거나 서비스 제공업체에 문의하십시오.

Vietnamese (Tiếng Việt)

LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi cung cấp miễn phí các dịch vụ hỗ trợ ngôn ngữ. Các hỗ trợ dịch vụ phù hợp để cung cấp thông tin theo các định dạng dễ tiếp cận cũng được cung cấp miễn phí. Vui lòng gọi theo số 608-855-9698 (Người khuyết tật: 711) hoặc trao đổi với người cung cấp dịch vụ của bạn.

French (Français)

ATTENTION : Si vous parlez Français, des services d'assistance linguistique gratuits sont à votre disposition. Des aides et services auxiliaires appropriés pour fournir des informations dans des formats accessibles sont également disponibles gratuitement. Appelez le 608-855-9698 (TTY : 711) ou parlez à votre fournisseur.

Polish (Polski)

UWAGA: Osoby mówiące po polsku mogą skorzystać z bezpłatnej pomocy językowej. Dodatkowe pomoce i usługi zapewniające informacje w dostępnych formatach są również dostępne bezpłatnie. Zadzwoń pod numer 608-855-9698 (TTY: 711) lub porozmawiaj ze swoim dostawcą.

Albanian (Shqip)

VINI RE: Nëse flisni shqip, shërbime falas të ndihmës së gjuhës janë në dispozicion për ju. Ndihma të përshtatshme dhe shërbime shtesë për të siguruar informacion në formate të përdorshme janë gjithashtu në dispozicion falas. Telefononi 608-855-9698 (TTY: 711) ose bisedoni me ofruesin tuaj të shërbimit.

Tagalog (Tagalog)

PAALALA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga libreng serbisyong tulong sa wika. Magagamit din nang libre ang mga naaangkop na auxiliary na tulong at serbisyo upang magbigay ng impormasyon sa mga naa-access na format. Tumawag sa 608-855-9698 (TTY: 711) o makipag-usap sa iyong provider.

Need this notice in another format? Call 608-855-9698.