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Source: HHS Office for Civil Rights

Zugner & Pedersen Dental Group

complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Zugner & Pedersen Dental Group

does not exclude people or treat them differently because of race, color, national origin, age,

disability, or sex.

Zugner & Pedersen Dental Group:

– Provides free aids and services to people with disabilities to communicate effectively with

us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats)

– Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact William E. Zugner, D.D.S.

If you believe that Zugner & Pedersen Dental Group

has failed to provide these services or discriminated in another way on the basis of race,

color, national origin, age, disability, or sex, you can file a grievance with:

William E. Zugner, D.D.S.

55 North Ave., Webster, NY 14580

phone: 585-872-2797

fax: 585-872-5571

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,

William E. Zugner, D.D.S. is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue SW

Room 509F, HHH Building

Washington, DC 20201

Toll Free; 1-800-868-1019

800-537-7697 (TDD).

Complaint forms are available at

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We will take reasonable steps to provide free-of-charge language assistance services to people who
speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about
the dental care we are providing.

Tomaremos acciones razonables para proporcionar servicios de asistencia lingüística gratuitos a aquellas
personas cuyo lenguaje escuchemos frecuentemente en nuestro consultorio y que no hablen un inglés lo
suficientemente bueno como para hablar con nosotros sobre el servicio odontológico que suministramos.


Мы принимаем необходимые меры, чтобы предоставить бесплатные услуги переводчика для общения на
языках, с которыми мы сталкиваемся в нашей практике с клиентами, которые не владеют английским
языком достаточно, чтобы обсудить с нами стоматологическое обслуживание, которое мы предоставляем.

French Creole (Haitian Creole):
Nou pral pran mezi rezonab pou bay sèvis asistans lang gratis pou moun ki pale lang nou pagen ide deyo ak ki
pa pale angle byen ase pou pale ak nou sou swen dantè nou ap bay.

저희는 적절한 조치를 통하여 언어 지원 서비스를 무료로 제공할 것입니다. 다만, 실제로 저희에게 관심이 있는
언어를 쓰지만 저희 치아 관리 서비스에 대해의견을줄수있을만큼영어로의사소통이원활하지않는경우로

Adotteremo le misure ragionevoli per fornire servizi di assistenza linguistica gratuiti a coloro che parlano lingue
che sentiamo spesso sul posto di lavoro e che non parlano inglese abbastanza bene da poter discutere della cura
dentale che stiamo fornendo.

ןדער סאוו ןשנעמ וצ ןגנונידאב ףליה ךארפש עיירפ ןבעג וצ ןלטימ עכילראווטנאראפ ןמענ ןלעוו רימ
ןלעוו אמתסמ רימ סאוו ןכארפש ףליה לטנעד ןגעוו זנוא טימ ןדער וצ גונעג טוג שילגנע טינ ןדער סאוו ןוא קיטקארפ רזנוא ןיא ןרעה

Będziemy podejmować stosowne kroki, by zapewnić bezpłatne usługi wsparcia językowego dla ludzi, którzy
rozmawiają językami, które my chcielibyśmy słyszeć w naszym gabinecie i dla tych, którzy nie mówią po
angielsku na tyle dobrze, aby rozmawiać z nami o opiece stomatologicznej, którą zapewniamy.

Nous prendrons les mesures raisonnables pour fournir des services d’assistance linguistique gratuits pour les
individus qui parlent des langues que nous sommes susceptibles d’entendre durant nos séances et qui ne parlent
pas suffisamment bien l’anglais pour discuter avec nous concernant les soins dentaires que nous fournissons.

Gagawin namin ang mga makatwirang hakbang para maibigay namin ng walang bayad ang mga tulong na
serbisyo sa wika para sa mga taong nagsasalita ng mga wikang karaniwan naming naririnig sa aming
pagsasagawa at sa mga hindi bihasa sa pagsasalita ng Ingles na sasangguni sa amin tungkol sa pangangalaga
ng ngipin na ibinibigay namin.

Θα λάβουμε όλα τα αναγκαία μέτρα ώστε να παρέχουμε υπηρεσίες γλωσσικής βοήθειας δωρεάν-χωρίς-χρέωση
στους ανθρώπους εκείνους που είναι πιθανόν ότι θα μιλούν στη μητρική τους γλώσσα κατά τη διάρκεια της
εξέτασης και οι οποίοι δεν θα μιλούν τα αγγλικά αρκετά καλά ώστε να συνεννοηθούν με εμάς για την οδοντιατρική
φροντίδα που παρέχουμε.

Do të marrim hapa të arsyeshëm për të ofruar shërbime falas për asistencë gjuhësore për njerëzit që flasin gjuhë
që ka të ngjarë të dëgjojmë në punën tone dhe që nuk flasin anglisht aq mire sa të flasin me ne për kujdesin
dentar që ofrojmë.

Reproduction of this material by member dentists and their staff is permitted for non-commercial use in their
dental offices, on their websites, and on publications and communications for purposes of compliance with the
Section 1557 final rule. Any other use, duplication or distribution by members or any other party requires the prior
written approval of the American Dental Association.

This material is for general reference purposes only and does not constitute legal advice. It covers only the
Section 1557 final rule tagline requirement, not other federal or state law. Changes in applicable laws or
regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice
pertaining to compliance with Section 1557 of the Affordable Care Act, and the U.S. Department of Health and
Human Services rules and regulations.

© 2016 American Dental Association. All rights reserved.