Title VI Please complete this Title VI form below. If you have any questions call us on (615) 915-6090. Patient name:* First Last Patient date of birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 TITLE VI-State of Tennessee Department of Intellectual and Developmental Disabilities TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 REQUIRES THAT FEDERALLY ASSISTED PROGRAMS BE FREE OF DISCRIMINATION. THE TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ALSO REQUIRES THAT ITS ACTIVITIES BE CONDUCTED WITHOUT REGARD TO RACE, COLOR, OR NATIONAL ORIGIN. Prohibited Practices Include: Denying any individual any services, opportunity, or other benefit for which he or she is otherwise qualified; Providing any individual with any service or other benefit, which is different or is provided in a different manner from thatwhich is provided to others under the program; Subjecting any individual to segregated or separate treatment in any manner related to his or her receipt of service; Restricting any individual in any way in the enjoyment of services; facilities; or any other advantage, privilege, or benefitprovided to others under the program; Adopting methods of administration that would limit participation by any group of persons supported or subject them todiscrimination; Addressing an individual in a manner that denotes inferiority because of race, color, or national origin; Subjecting any individual to incidents of racial or ethnic harassment, the creation of a hostile racial or ethnic environment,and a disproportionate burden of environmental health risks on minority communities. Should you feel you have been discriminated against, please contact the local Title VI coordinator. Name: Jason TaylorTitle: Chief Operating OfficerAddress: 330 Wallace Road, Suite 106, Nashville, TN 37221Phone: 615-915-6106Fax: 615-915-6091 Any individual may file a Title VI complaint with the below listed entities. It is preferable that complaints beregistered at the local level first. DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILTIES Title VI Compliance Director: Vickey Coleman, Ph.D.315 Deaderick Street NASHVILLE, TN 37243 or U.S. DEPARTMENT OF JUSTICECOORDINATION & REVIEW SECTION - NYA CIVIL RIGHTS DIVISION 950 PENNSYLVANIA AVENUE, N.W. WASHINGTON, D.C. 20530(888) 848-5306 (toll free voice and TDD) DIDD-0524 Rev. 05/2019 SubmitName of Legal Guardian or Authorized Representative:*If not applicable use 'self'Today's date:* Date Format: MM slash DD slash YYYY Do you wish to receive a copy of this Consent?*YesNoE-mail address:* Please sign*Important: You consent to sign this document electronically.