Complete the Federal Complaint Form

HOW TO

Preview all of the form questions along with BD SUMHAC’s recommended answers below. Start your complaint here.

Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of disability in programs and activities that receive Federal financial assistance as well as in programs and activities conducted by any Federal agency.

Question 1 - Your first and last name

Question 2 - Your phone number

Question 2 - Your address

  • Note: If you are filing the complaint on behalf of someone else, the first and last name of the person whose civil rights were violated (the person who received a denial to a mental health and/or substance use disorder treatment facility because of their bleeding disorder)

  • Select “disability”

    1. Person or Agency/Organization: [select agency/organization]

    2. Name of Agency/Organization

    3. Agency/Organization’s address

    4. Agency/Organization’s phone number (optional)

  • Insert specific dates (Please submit the date of the first denial and the length of time that you waited for placement or until discharge).

  • Please be as specific as possible. Be prepared to submit a succinct summary of the incident that describes the context, the specific reason(s) that they gave for denying access, etc.  Possible reasons include:

    o   Bleeding disorders are too medically complex.

    o   They can’t manage the infusions/injections.

    o   They don’t allow needles in our facility.

    o   An insurance issue related to bleeding disorder medication.

    o   An issue related to accessing medication at the specialty pharmacy.

    Only 4,000 characters are allowed in the text box. However, they do allow you to upload additional files if you need to include more details.

Question 9 - Documentation of discrimination

Question 10 - Optional demographic information

  • Please enter BD SUMHAC

Question 12 - You will be asked to sign this form

Question 13 - You will be asked to give consent by signing this form

You will have an option to print or PDF a copy of the complaint before you submit. When the complaint has been submitted, you will receive a confirmation form that looks like this.

< Screening Tips for Federal Complaints | Appealing the Decision at the Facility Level >

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