Fillable 1044-DHCS-DISCRIMINATION-COMPLAINT-FORM DHCS 1044 Discrimination Complaint Form (Title VI and ADA)

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1044-DHCS-DISCRIMINATION-COMPLAINT-FORM DHCS 1044 Discrimination Complaint Form (Title VI and ADA)

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State of California – Health and Human Services Agency Department of Health Care Services
Office of Civil Rights
DHCS DISCRIMINATION COMPLAINT FORM (TITLE VI AND ADA)
CONFIDENTIAL
Federal law states that all organizations receiving federal money must take steps to ensure that
federal money is not used for a discriminatory purpose. Therefore all people and organizations
providing Medi-Cal assistance in California must respect a consumer’s rights and prohibit
discrimination in the administration of Medi-Cal services (this includes the people and organizations
determining Medi-Cal eligibility and Medi-Cal service providers). The Department of Health Care
Services (DHCS) Office of Civil Rights (OCR) has established this complaint process for Medi-Cal
consumers to voice complaints of alleged discrimination against any individual or organization that
they believe has engaged in a prohibited discriminatory practice.
In regard to complaints of discrimination the complainant has a right to:
• File a written complaint with the Department of Health Care Services (DHCS) Office of Civil
Rights (OCR) within three hundred sixty-five (365) days from the alleged unlawful
discrimination. The written complaint must state the action perceived to be discriminatory, the
basis of discrimination, and the specific remedy(ies) sought by the complainant
• File an Unruh Civil Rights complaint with the Department of Fair Employment and Housing
(DFEH), the complainant is required to file such complaint within one (1) year from the alleged
discriminatory act
• File a complaint under Title VI of the Civil Rights Act of 1964, Title II of the Americans with
Disabilities Act (ADA) of 1990 and other applicable state and federal laws with both the federal
Health and Human Services Office of Civil Rights (HHS OCR) and/or the DHCS OCR. A
complainant is required to file a complaint within on-hundred-eighty (180) days from the
alleged discriminatory act
• An impartial investigation
• Have a representative chosen and paid for by the complainant present at all stages of the
process
• Be free from restraint, interference, coercion, or retaliation
• Ask the HHS OCR to review the action of the DHCS Office of Civil Rights
The complainant has a responsibility to:
Provide accurate and factual information during all phases of the complaint process.
I have read and understand these rights and responsibilities.
Signature
Date
DHCS 1044 (Revised 02/2020) Page 1 of 2
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State of California – Health and Human Services Agency Department of Health Care Services
Office of Civil Rights
CIVIL RIGHTS EXTERNAL COMPLIANCE PROGRAM
COMPLAINT OF DISCRIMINATION (TITLE VI and ADA)
Complete and return to:
Department of Health Care Services
Office of Civil Rights, MS 0009
PO Box 997413
Sacramento, CA 95899-7413
NAME DATE
ADDRESS E-MAIL ADDRESS
PHONE NUMBER
I believe that I have been discriminated against on the basis of:
RACE NATIONAL ORIGIN RELIGION AGE
GENDER COLOR DISABILITY
(including HIV Status)
OTHER
NAME & ADDRESS OF MEDI-
CAL
ADMINISTRATOR/PROVIDER
NAME & TITLE OF
PERSON COMPLAINED OF
(Respondent)
DATE OF
OCCURRENCE
PHONE
NUMBER
(Respondent)
Describe in your own words what action(s) have happened to lead you to believe you have been
discriminated against.
Indicate what resolution you are seeking.
I understand the above information is true and complete to the best of my knowledge and belief.
COMPLAINANT’S PRINTED
NAME
COMPLAINANT’S OR AUTHORIZED
REPRESENTATIVE SIGNATURE
DATE
DHCS 1044 (Revised 02/2020) Page 2 of 2
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1044-DHCS-DISCRIMINATION-COMPLAINT-FORM DHCS 1044 Discrimination Complaint Form (Title VI and ADA)

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Completed 3 July 2020

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