Use this SOP to protect the civil rights of patients with disabilities, provide equal access to Besa Health programs and services, maintain accessible facilities and communication, and respond correctly to accommodation requests or discrimination complaints.
☎ Civil Rights Complaint Help
HHS Office for Civil Rights: (800) 368-1019 | TDD: (800) 537-7697
File A Civil Rights Complaint Online • HHS Office For Civil Rights
📚 Resources Needed
Consumer civil rights notice posted in a prominent clinic location
Information explaining the right to communication assistance for people with disabilities and people with limited English proficiency
Besa Health Member Grievances and Complaints SOP
24-hour telephone, video, or on-site interpreter services
Accessible communication formats and appropriate auxiliary aids and services
Current facility accessibility review and any documented reasonable-alternative plans
Staff training materials covering the ADA, Section 504, and Section 1557
✅ Before You Start
Section 504 of the Rehabilitation Act of 1973 protects qualified individuals from disability-based discrimination and applies to organizations receiving federal financial assistance, including assistance from the U.S. Department of Health and Human Services.
Qualified individuals with disabilities must have an equal opportunity to participate in and receive program benefits and services. They may not be denied services, benefits, participation, or access because of physical barriers.
A disability includes a physical or mental impairment that substantially limits one or more major life activities, a history of such an impairment, or being regarded as having such an impairment.
Major life activities include caring for oneself, walking, seeing, hearing, speaking, breathing, working, performing manual tasks, and learning.
Examples of impairments that may substantially limit major life activities, even with medication or aids and devices, include AIDS, alcoholism, blindness or visual impairment, cancer, deafness or hearing impairment, diabetes, drug addiction, heart disease, and mental illness.
Section 504 protections apply to service availability, accessibility, delivery, employment, and the administrative activities and responsibilities of federally funded organizations.
Section 1557 of the Affordable Care Act prohibits discrimination based on race, color, national origin, sex, age, or disability in covered health programs and activities.
Covered entities must provide effective communication and appropriate auxiliary aids and services; maintain accessible buildings, facilities, electronic information, and technology; and make reasonable modifications to policies, procedures, and practices when necessary for access.
Facilities designed, constructed, or altered for use by a public entity must meet applicable accessibility requirements under 28 CFR 35.151. Altered portions of public accommodations and commercial facilities must be made accessible to the maximum extent feasible.
The clinic must meet applicable city, county, and state building and access requirements. The site includes the building, walkways, parking lots, and equipment.
✅ Confirmed Accessibility Accommodations
The following accommodations have been confirmed as available at Besa Health:
☑ Exit and exam-room doorway openings provide at least 32 inches of clear passage with the door open at 90 degrees.
☑ Door hardware is operable with a single effort and does not require grasping, such as latches or push bars instead of door knobs.
☑ The effort required to operate interior doors does not exceed 5 pounds of pressure.
☑ Furniture and other items do not obstruct exit doorways or interfere with door-swing pathways.
☑ Waiting and exam areas provide at least 30 by 48 inches of clear floor space for a stationary adult wheelchair and occupant, plus a 60-inch-diameter or square clear area for wheelchair turning.
☑ Wheelchair-accessible restroom facilities are available.
☑ Wheelchair-accessible handwashing facilities are available.
☑ Twenty-four-hour language and hearing-impaired interpreter services are available through telephone, video, or on-site interpreters.
☑ Signage is provided in raised letters and Braille.
🔎 Items Requiring Verification Or A Documented Alternative
Compliance or the designated site leader must verify each applicable item below. If an item is unavailable, document a reasonable alternative that makes program services available to people with physical disabilities.
Accessible parking spaces are located close to accessible building entrances.
Accessible parking spaces have permanently affixed, reflectorized signs in conspicuous locations, or the clinic has a documented reasonable alternative when it does not control accessible parking in the lot or nearby street spaces.
Pedestrian ramps have clear, level landings at the top and bottom and on each side of an exit door when the clinic has multiple levels.
An accessible passenger elevator is available for multi-level access, or a documented reasonable alternative is in place.
Other accommodations or specialized equipment are available as patient needs require, including height-adjustable exam tables and wheelchair-accessible weight scales, or a reasonable alternative is documented.
📘 Instructions
Step 1 Post Required Civil Rights Information
Post the consumer civil rights notice in a prominent clinic location.
Post information explaining the right to communication assistance for patients with disabilities and patients with limited English proficiency.
Keep notices readable, current, and available in accessible or translated formats when needed.
Step 2 Provide Equal Access And Reasonable Modifications
Do not exclude or deny a qualified individual the opportunity to participate in or benefit from covered programs, services, or other benefits.
Do not deny access because of a physical, communication, technological, policy, or procedural barrier.
Ask what accommodation or communication method is effective for the patient. Do not make assumptions based on appearance or diagnosis.
Provide reasonable modifications to policies, procedures, and practices unless Compliance determines that a requested change is not required under applicable law.
Protect the patient's privacy and discuss disability-related information only with team members who need it to provide care or services.
Step 3 Maintain Physical Accessibility
Keep exit routes, doorways, door-swing paths, waiting areas, exam rooms, restrooms, and handwashing areas clear and usable.
Do not move furniture or equipment into required wheelchair floor space or turning space.
Report any broken door hardware, excessive door resistance, inaccessible fixture, missing Braille or raised-letter signage, or other barrier immediately.
Do not direct a patient away from care because an accessibility feature is unavailable. Notify the site leader and arrange a safe, effective alternative.
Step 4 Provide Effective Communication
Offer appropriate auxiliary aids and services or accessible formats based on the patient's communication needs.
Use the clinic's 24-hour telephone, video, or on-site interpreter service for language or hearing-related communication assistance.
Communicate directly with the patient, allow adequate response time, and confirm understanding of important information.
Do not charge the patient for required communication assistance.
Step 5 Respond To A Discrimination Complaint
Listen without arguing, retaliating, discouraging the complaint, or delaying needed care.
Address any immediate safety, access, or communication need.
Provide the patient with the Besa Health Member Grievances and Complaints process and notify the designated supervisor or Compliance team.
Explain that a person who believes they experienced discrimination in health care or health coverage may file a Section 1557 complaint with the HHS Office for Civil Rights.
Provide the OCR website or complaint portal and the toll-free numbers: (800) 368-1019 or (800) 537-7697 for TDD assistance. OCR complaint forms are available in multiple languages.
Do not tell the patient that the internal grievance process replaces or limits their right to contact OCR or pursue other legal remedies, including a lawsuit under Section 1557.
Step 6 Apply The Civil Rights Grievance Procedure When Required
For sites with 15 or more employees, maintain and follow a civil rights grievance procedure.
Designate an employee to coordinate civil rights compliance and identify that person in the clinic's civil rights materials.
Process all civil rights discrimination complaints under the Besa Health Member Grievances and Complaints policy.
Document the complaint, actions taken, referrals, accommodations provided, and follow-up without placing unnecessary disability details in general-access records.
Step 7 Train All Site Personnel
Provide all site personnel with information or training on patient rights and provider obligations under the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Section 1557 of the Affordable Care Act.
Training must cover physical access, reasonable accommodations, policy modifications, and effective communication in health care settings.
Provide refresher training when procedures, resources, facility conditions, or applicable requirements change.
Step 8 Review And Document Accessibility
Periodically review the clinic's building, walkways, parking areas, equipment, communication resources, notices, and training records.
Record confirmed accommodations, barriers, repair requests, and reasonable-alternative plans.
Escalate unresolved access barriers to the site leader and Compliance team and track them through resolution.
🛠 Troubleshooting
A Required Accessibility Feature Is Temporarily Unavailable
Do not refuse or postpone service solely because of the barrier. Keep the patient safe, contact the site leader, arrange a reasonable alternative that provides meaningful access, and document the barrier and corrective action.
A Patient Requests An Accommodation The Team Has Not Used Before
Ask the patient what works for them, contact the supervisor or Compliance team, and make a prompt individualized decision. Do not deny the request based only on inconvenience, unfamiliarity, assumptions, or stereotypes.
The Patient Reports Discrimination
Address the immediate care or access need, provide the internal grievance process and OCR complaint information, notify Compliance, document the report objectively, and prevent retaliation.
An Accessibility Item Has Not Been Verified
Do not mark it as confirmed. Arrange an accessibility review and document either the compliant feature or the reasonable alternative used to make services available.
✅ Completion Check
The consumer civil rights and communication-assistance notices are posted prominently.
The nine confirmed accessibility accommodations remain available and unobstructed.
Every other applicable physical-access item has been verified or has a documented reasonable alternative.
The patient received effective communication, accessible information, and reasonable modifications when needed.
No patient was denied services or participation because of disability or a physical barrier.
Complaints were routed through the Member Grievances and Complaints policy and OCR information was provided when applicable.
Sites with 15 or more employees maintain a civil rights grievance procedure and designated compliance coordinator.
All site personnel completed the required disability-rights and provider-obligations training.
References
HHS Section 504 Detailed Fact Sheet
CalOptima Referenced Section 504 Fact Sheet
Electronic Code Of Federal Regulations Search
Referenced Attachments: Notice of Nondiscrimination sample; Statement of Nondiscrimination sample; Physical Accessibility Review Survey Information and Tools
Source: CalOptima Provider FSR/MRR Binder, pages 143-145 • Revised Apr 20, 2026
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