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 BD)

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 BD 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.