At MedForms, we work to ensure your patient admission booklets are kept up to date with changing regulations. We have recently updated the Notice of Nondiscrimination section in all booklets to align with the requirements detailed in the Final Rule. The updates include contact information for your agency’s Civil Rights Coordinator, as well as your agency’s website where the Notice of Nondiscrimination is posted.
Below are several frequently asked questions about the Final Rule and how it affects your Notice of Nondiscrimination as well as questions about the Civil Rights Coordinator. If you have any additional questions, you can always reach us by phone at (615) 386-6320.
Do we have to provide a Notice of Nondiscrimination to our patients?
Yes. Agencies must, at minimum, provide the Notice to patients annually, as well as upon request, on the agency’s website (if it has one), and post it in the agency’s physical location.
What is a Civil Rights Coordinator?
Also called a Section 1557 Coordinator, the Final Rule defines the duties of the Civil Rights Coordinator/Section 1557 Coordinator.
Do we have to have a Civil Rights Coordinator?
Yes. Any agency that employs fifteen or more persons must designate and authorize at least one employee, as a Civil Rights/Section 1557 Coordinator. The Office for Civil Rights counts full-time employees, part-time employees and independent contractors toward this 15-employee threshold. All employees, regardless of job classification (e.g., clinical versus clerical), will count toward the threshold.
Note: Agencies who are below the 15-employee threshold still must distribute a Notice of Nondiscrimination to their patients, but they are not required to include information about a Civil Rights Coordinator.
Do they have to have the title “Civil Rights Coordinator?”
No. As long as the employee fulfills the defined role of Civil Rights Coordinator/Section 1557 Coordinator that person can use a different title.
What contact information for the Civil Rights Coordinator needs to be provided to the patient?
Phone number, email address and mailing address. An agency may establish a general phone number, email address, and/or mailing address to meet this requirement.
Must this Notice be posted to my agency’s website?
Yes, if your agency has a website, you are required to post the notice in its entirety in a conspicuous location on your website. Most agencies choose to add a link to the Notice at the bottom of their home page.
What are the required reasons for Nondiscrimination?
At minimum, agencies need to include all the reasons from Section 1557, which are listed in the sample notice. We also recommend including the parenthetical statement for national origin because it is included in the text of the Final Rule
Additionally, we strongly recommend including the following parenthetical statement for sex given in the Final Rule and the sample notice: (including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity and sex stereotypes). It is acceptable to use the shorter parenthetical option given in the sample notice – (consistent with the scope of sex discrimination described at [45CFR § 92.101(a)(2) – but we do not recommend this option because it is not patient friendly, and most patients will not understand what the reference means.
What do I do if I still have a large supply of admission booklets without these changes by the required implementation date?
Use this sample notice to develop a notice for your agency to provide as a supplement to your admission booklet until the next time you order booklets from MedForms. At the time of your next reorder, MedForms will update your booklet with the latest requirements, including the Notice of Nondiscrimination.
Does the Final Rule also require that we include a Language Page?
Yes, the Final Rule requires that agencies begin distributing a Notice of Availability of Language Assistance Services and Auxiliary Aides and Services by July 05, 2025. MedForms will begin adding this information to your booklet in early 2025. This item will include a notification in English as well as in the top 15 non-English languages spoken in your state(s).
When do I need to be in compliance with the Final Rule’s requirements regarding the Notice of Nondiscrimination to my patients?
This Civil Rights Coordinator and Notice of Nondiscrimination portion of the Final Rule is effective 7/5/24 and the implementation date is 11/5/24.
