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