Notice of My Healthcare Rights My name is _______________________________________. My rights as a person with a disability, older adult with conditions of aging, and/or individual with limited English proficiency are not to be violated during the COVID-19 crisis. I expect this healthcare facility and all staff to follow the guidance bulletin released by the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) titled ÒCivil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19)Ó on March 28th, 2020. This includes but is not limited to: (Check all boxes that apply) * Deliver effective communication through the use of qualified interpreters (including ASL), adaptive technology/equipment, picture boards, and other means. * Make emergency messaging available in multiple formats (i.e. plain language, other languages, audio, captioning, alternative print (including large print and Braille). * Support my mobility needs (i.e. assistive devices, personal mobility devices, durable medical equipment, personal ventilator). * Allow me to bring my service animal with me. * Meet my reasonable accommodation or modification requests, as needed. * Respect my requests for religious accommodations (access to clergy or other faith practices). * Permit a family member or other support person to be with me (unless they are also sick). * Help me plan and schedule appropriate follow-up care services. * Adhere to any personal legal documents concerning my healthcare and end of life choices (i.e. Living Will, Healthcare Power of Attorney, DNR Orders, Supported Decision-Making Agreement). * Provide all healthcare services and medical equipment necessary in order to save my life. I am equipped to advocate for my rights as a person with a disability/older adult with conditions of aging/individual with limited English proficiency. Failure to adhere to my rights will result in complaints made to the following agencies and service providers: (Check all boxes that apply) * Department of Justice, Civil Rights Division and/or Disability Rights Section * Department of Health and Human Services, Office of Civil Rights * Indiana Disability Rights * Indiana Legal Services * Indiana Statewide Independent Living Council * Indiana Centers for Independent Living I am requesting that you provide means for me to contact my personal representative(s) for assistance while I am receiving healthcare services: (Check all boxes that apply) * My attorney * My healthcare power of attorney, healthcare representative or decision-maker support representative * My Independent Living Advocate * ____________________ * ____________________ * ____________________ (List other personal representative(s). This may include a family member, friend, personal care attendant, direct support professional, or any other individual you feel helps provide necessary support). Notice of My Healthcare Rights COMPLAINT & ADVOCACY SUPPORT CONTACT INFORMATION Department of Justice, Civil Rights Division Toll-free:Ê855-856-1247 orÊ202-514-3847 Ð Civil Rights Division Office: 202-307-0663 Ð Disability Rights Section https://www.ada.gov/complaint/form.php?language=en Department of Health and Human Services, Office of Civil Rights Toll-free: 800-368-1019 https://www.hhs.gov/ocr/complaints/index.html Indiana Disability Rights Toll-free: 800-622-4845 or 317-722-5555 Email: info@IndianaDisabilityRights.org Indiana Legal Services Toll-free: 844-243-8570 https://ilsoi.legalserver.org/modules/matter/extern_intake.php?pid=129&h=daa817& Indiana Statewide Independent Living Council Toll free: 844-446-7452 Email: info@insilc.org Indiana Centers for Independent Living accessABILITY Office: 317-926-1660 Toll-free: 866-794-7245 Assistive Technology & Training Information Center, Inc. (ATTIC) Office: 812-886-0575 Toll-free: 877-962-8842 Everybody Counts Office: 219-769-5055 Everybody Counts North Office: 219-937-5055 Future Choices Office: 765-741-8332 Toll-free: 866-741-3444 The Independent Living Center of Eastern Indiana (ILCEIN) Office: 765-939-9226 Toll-free: 877-939-9226 The League Office: 260-441-0551 Toll-free: 800-889-3443 Southern Indiana Center for Independent Living (SICIL) Office: 812-277-9626 Toll-free: 800-845-6914 Southeastern Indiana Independent Living Center (SIILC) Office: 812-427-3333 The Wabash Independent Living and Learning Center (The WILL Center) Office: 812-298-9455 Toll-free: 877-915-9455 #WeAreEssential #BeTheVoice