Non-Discrimination Form - Colorado Access

Nondiscrimination Notice
Non-Discrimination Form

Purpose:
This form is for individuals to report instances of discrimination related to health plan services, including discrimination based on race, color, national origin, disability, age, sex, gender identity, sexual orientation, or other protected characteristics.

Non-Discrimination Complaint Form

Complaint Information

Full Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number(Required)

Email Address(Required)

Preferred Contact Method(Required)

Phone

• Are you filing this complaint on behalf of someone else?

Yes

If Yes, please provide the person’s name and relationship to you.

Incident Details

Date of incident(Required)

Person(s) or provider(s) involved:(Required)

Location/Facility Where the Incident Occurred:(Required)

Type of Service Received:(Required)

Description of the Incident:(Required)

Basis for Complaint

Type of Discrimination Alleged: (Race, Color, National Origin, Age, Disability, Sex, Gender Identity, Sexual Orientation. Other (Please specify):(Required)

Witness Information (If applicable)

Were there any witnesses to the incident?(Required)

Yes

If Yes, please provide their name(s) and contact information:

Resolution Sought

What would you like the Colorado Access to do in response to your complaint?(Required)