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HHS Notifications and Statements


English
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice english
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement english


Español (Spanish)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice spanish
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement spanish


hhs bad char chinese (Chinese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice chinese trd
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement chinese trd


Tiếng Việt (Vietnamese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice vietnamese
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement vietnamese


hhs bad char korean (Korean)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice korean
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement korean


Tagalog (Tagalog – Filipino)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice tagalog
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement tagalog


Русский (Russian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice russian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement russian


العربية(Arabic)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice arabic
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement arabic


Kreyòl Ayisyen (French Creole)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice french creole haitian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement french creole haitian


Français (French)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice french
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement french


Polski (Polish)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice polish
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement polish


Português (Portuguese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice portuguese european
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement portuguese european


Italiano (Italian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice italian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement italian


Deutsch (German)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice german
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement german


hhs bad char japanese (Japanese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice japanese
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement japanese


فارسی (Farsi)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice persian farsi
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement persian farsi


हिंदी (Hindi)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice hindi
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement hindi


Հայերեն (Armenian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice armenian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement armenian


ગુજરાતી (Gujarati)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice gujarati
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement gujarati


Hmoob (Hmong)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice hmong
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement hmong


اُردُو (Urdu)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice urdu
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement urdu


ខ្មែរ (Cambodian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice cambodian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement cambodian


ਪੰਜਾਬੀ (Punjabi)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice panjabi
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement punjabi


বাংলা (Bengali)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice bengali
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement bengali


אידיש(Yiddish)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice yiddish
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement yiddish


አማርኛ (Amharic)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice amharic
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement amharic


ภาษาไทย (Thai)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice thai
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement thai


Oroomiffa (Oromo)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice cusite oromo
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement cusite oromo


Ilokano (Ilocano)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice ilocano
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement ilocano


ພາສາລາວ (Lao)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice lao
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement lao


Shqip (Albanian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice albanian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement albanian


Srpsko-hrvatski (Serbo-Croatian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice serbo croatian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement serbo crotian


укРаїнська (Ukrainian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice ukrainian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement ukrainian


नेपाली (Nepali)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice nepali
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement nepali


Nederlands (Dutch)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice dutch
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement dutch


unD (Karen)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice karen
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement karen


Gagana fa'a Sāmoa (Samoan)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice samoan
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement samoan


Kajin Ṃajōḷ (Marshallese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice marshallese
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement marshallese


Română (Romanian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice romanian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement romanian


Foosun Chuuk (Trukese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice trukese
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement trukese


Tonga (Tongan)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice tongan
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement tongan


Bisaya (Bisayan) .
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice bisyan
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement bisyan


Ikirundi (Bantu – Kirundi)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice bantu kirundi
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement bantu krundi


Kiswahili (Swahili)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice swahili
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement swahili


Bahasa Indonesia (Indonesian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice indonesian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement indonesian


Türkçe (Turkish)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice turkish
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement turkish


کوردی (Kurdish)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice kurdish
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement kurdish


తెలుగు (Teluga)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice teluga
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement teluga


Thuɔŋjaŋ (Nilotic – Dinka)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice nlotic dinka
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement nilotic dinka


Norsk (Norwegian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice norwegian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement norwegian


Català (Catalan)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice catalan
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement catalan


λληνικά (Greek)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice greek
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement greek


Igbo asusu (Ibo)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice ibo
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement ibo


èdè Yorùbá (Yoruba)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice yourba
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement yourba


Lokaiahn Pohnpei (Pohnpeian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice pohnpeian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement pohnpeian


Deitsch (Pennsylvania Dutch)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice pennsylvania dutch
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement pennslyvania dutch


hoʻokomo ʻōlelo (Hawaiian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice hawaiian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement hawaiian


Adamawa (Fulfulde)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice fulfulde
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement fulfulde


tsalagi gawonihisdi (Cherokee)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice cherokee
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement cherokee


I linguahén Chamoru (Chamorro)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice chamorro
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement chamorro


ܣܘܼܪܸܬ݂ (Assyrian)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice assyrian
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement assyrian


Burmese written in Burmese characters. (Burmese)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice burmese
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement burmese


Diné Bizaad (Navajo)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice navajo
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement navajo


hhs bad char bassa (Bassa)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice bassa
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement bassa


Chahta (Choctaw)
» Notice of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce notice choctow
» Statement of Nondiscrimination

[Name of covered entity] Summit Dental - William Samson DDS
[Mailing address] REPLACE: Civil Rights Coordinator Mailing Address
[Telephone number] REPLACE: Civil Rights Coordinator PHONE
[TTY number—if covered entity has one] REPLACE: Civil Rights Coordinator TTYPHONE
[FAX] REPLACE: Civil Rights Coordinator FAX
[Email] REPLACE: Civil Rights Coordinator EMAIL
[Name of civil rights coordinator] REPLACE: Civil Rights Coordinator
[Name and Title of Civil Rights Coordinator] REPLACE: Name And Title Of Civil Rights Coordinator
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

sample ce statement choctow
Bozeman Location:


Ennis Location:

Contact Us


Bozeman Office Location

Ennis Office Location
406-404-1186
email:info@bozemandentalcare.com

Bozeman Location


Office Hours
Monday
Tuesday
Wednesday
Thursday
Friday
7:00am-3:00pm
7:00am-5:00pm
7:00am-5:00pm
7:00am-5:00pm
8:00am-4:00pm

Ennis Location NN


Office Hours
Monday
Tuesday
Wednesday
Thursday
Friday
Closed
8:00am-5:00pm
8:00am-5:00pm
8:00am-5:00pm
Closed
hhs notification dark for light
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Summit Dental - William Samson DDS, 3997 Valley Commons Drive Suite A Bozeman MT 59718; 406-404-1186; bozemandentalcare.com; 2/28/2025; Related Terms: dentist Bozeman MT;