Violation of Civil Rights (Based on Race, Color, National Origin, Disability, Age, or Sex) Select this because a denial based on a bleeding disorder is discrimination based on disability.

Violation of Conscience or Religious Freedom

Violation of Privacy or Security of Health Information (HIPAA)

The most recent incident was within the last six months 

1. Select this if you were eventually able to gain access to a facility or you were discharged and you are no longer seeking inpatient/residential behavioral health treatment.

The most recent incident was over six months ago

1. Select this if you were eventually able to gain access to a facility or you were discharged and you are no longer seeking inpatient/residential behavioral health treatment. If you select this answer, you will get a response that states, “Please note that under our regulations, OCR normally can accept only complaints that are filed within 180 days of when a complainant knew or should have known that the alleged violation occurred. Based on the information provided, this complaint is untimely. If you would like to file this complaint anyway, please include an explanation for why you waited over six months to file. Please note that you must have a very good reason for waiting so long to file in order to get the time period waived.” Although complaints may be untimely, the Office of Civil Rights has encouraged the bleeding disorder community to submit them anyway as they are trying to better understand the pattern of discrimination that has been facing the bleeding disorder community for years.

It is ongoing 

1. Select this if you are still seeking inpatient/residential behavioral health treatment.

Yes

No Select “no” if the primary concern is the mental health and/or substance use disorder treatment facility’s decision to deny you access based on your bleeding disorder

Yes

No Select “no” if the primary concern is the facility’s decision to deny you access based on your bleeding disorder

Yes

No Select “no” if the primary concern is the  facility’s decision to deny you access based on your bleeding disorder

Yes

No Select “no” if the primary concern is the facility’s decision to deny you access based on your bleeding disorder

Yes

No Select “no” if the primary concern is the facility’s decision to deny you access based on your bleeding disorder

Yes

No Select “no” if the primary concern is the facility’s decision to deny you access based on your bleeding disorder

Yes

No Select “no” if the primary concern is the  facility’s decision to deny you access based on your bleeding disorder

Yes Select “yes”

No