Form DOH-4487 "Americans With Disabilities Act (Ada) Complaint" - New York

What Is Form DOH-4487?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2010;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH-4487 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-4487 "Americans With Disabilities Act (Ada) Complaint" - New York

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NEW YORK STATE DEPARTMENT OF HEALTH
Americans with Disabilities Act (ADA) Complaint
Bureau of Health Insurance Program
Title II of the Americans with
Please complete this form and return to: � Denise DiPace
Disabilities Act (ADA) is intended
Department of Health
to protect qualified individuals with
Division of Legal Affairs
disabilities from discrimination on
Empire State Plaza
the basis of disability in the benefits,
Corning Tower, Room 2415
programs and services provided by all
Albany, NY 12237
state and local governments.
Please Print Clearly
The Federal Government defines
Complainant�
“qualified individual with a disability”
as “an individual with a disability
Name�
who, with or without reasonable
modifications to rules, policies,
Address Where Complainant Currently Resides�
or practices, ..., or the provision of
auxiliary aids and services, meets
the essential eligibility requirements
for the receipt of services or the
participation in programs or activities
Telephone�
provided by a public entity.” All state
and local government programs and
Complainant’s Authorized Representative�
the services and/or benefits provided
by or through those programs that
Name�
receive Federal assistance must
comply with Title II of the ADA.
Address�
Please be advised that employment
related ADA complaints do not fall
within the scope of Title II.
Telephone
The New York State Department of
Health (DOH) administers, regulates
Medicaid CIN # (if applicable)
and/or provides funding to a number
of health insurance and other health
Location of Local Social Services District (if applicable)
programs throughout the State. These
programs include, but are not limited
to, Medicaid, Family Health Plus, and
Provide a description of the alleged discrimination, including the name of the specific
Child Health Plus.
person(s), program(s) and/or facility(ies) the complainant believes is/are responsible for
If you are receiving a benefit, program
the discrimination.
or service that is administered,
funded, or regulated by DOH and you
feel you have been discriminated
against on the basis of disability,
you may fill out the complaint form
below and mail it to the address listed
on the form. Alternatively, you may
send a letter stating your complaint
and including all of the information
requested in the complaint form.
Date of Alleged Discrimination
DOH-4487 (2/10)
NEW YORK STATE DEPARTMENT OF HEALTH
Americans with Disabilities Act (ADA) Complaint
Bureau of Health Insurance Program
Title II of the Americans with
Please complete this form and return to: � Denise DiPace
Disabilities Act (ADA) is intended
Department of Health
to protect qualified individuals with
Division of Legal Affairs
disabilities from discrimination on
Empire State Plaza
the basis of disability in the benefits,
Corning Tower, Room 2415
programs and services provided by all
Albany, NY 12237
state and local governments.
Please Print Clearly
The Federal Government defines
Complainant�
“qualified individual with a disability”
as “an individual with a disability
Name�
who, with or without reasonable
modifications to rules, policies,
Address Where Complainant Currently Resides�
or practices, ..., or the provision of
auxiliary aids and services, meets
the essential eligibility requirements
for the receipt of services or the
participation in programs or activities
Telephone�
provided by a public entity.” All state
and local government programs and
Complainant’s Authorized Representative�
the services and/or benefits provided
by or through those programs that
Name�
receive Federal assistance must
comply with Title II of the ADA.
Address�
Please be advised that employment
related ADA complaints do not fall
within the scope of Title II.
Telephone
The New York State Department of
Health (DOH) administers, regulates
Medicaid CIN # (if applicable)
and/or provides funding to a number
of health insurance and other health
Location of Local Social Services District (if applicable)
programs throughout the State. These
programs include, but are not limited
to, Medicaid, Family Health Plus, and
Provide a description of the alleged discrimination, including the name of the specific
Child Health Plus.
person(s), program(s) and/or facility(ies) the complainant believes is/are responsible for
If you are receiving a benefit, program
the discrimination.
or service that is administered,
funded, or regulated by DOH and you
feel you have been discriminated
against on the basis of disability,
you may fill out the complaint form
below and mail it to the address listed
on the form. Alternatively, you may
send a letter stating your complaint
and including all of the information
requested in the complaint form.
Date of Alleged Discrimination
DOH-4487 (2/10)