Ada Complaint Form
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Please fill out this form completely, in black ink or type. Web filing an ada complaint is easy. Ada policy promotes use and acceptance of the most current version of the ada dental claim form by dentists and payers. Name* (first, middle initial, and last) home phone* business phone email address state agency accused of denying disability access agency* department (if applicable) agency address phone number email incident details date of incident*
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Web persons who want to file a complaint for reasons involving disability discrimination may do so, by completing this form and submitting it via u.s. Department of justice civil rights division 950 pennsylvania avenue, nw washington, dc 20530 3. To file a complaint using by mail, send your complaint form to the following address: Web title ii of the americans with disabilities act section 504 of the rehabilitation act of 1973 discrimination complaint form.
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