Fillable Commonwealth of Massachusetts Discrimination Grievance Form

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Commonwealth of Massachusetts Discrimination Grievance Form

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The Commonwealth of Massachusetts Discrimination Grievance Form form is 2 pages long and contains:

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Discrimination Complaint Form
If you believe that you have been (or someone else has been) discriminated against because of race, color,
national origin, age, disability, religion, creed, sexual orientation, or sex (including gender identity and
gender stereotyping) by the MassHealth agency, you may submit a complaint (also known as a grievence)
with the Section 1557 Compliance Coordinator. You may submit a complaint for yourself or for someone
else.
Please complete the information below and either mail, fax, or e-mail the completed form to the
addresses listed below. Note that in our e orts to investigate your complaint, we may contact you and
other relevant individuals or entities.
Please print.
Name First Last
Mailing address Street
City State Zip
E-mail if available Phone number
Social security number or MassHealth ID number
Are you submitting this complaint for someone else? Ye s No
If yes, who?
I believe that I have been (or someone else has been) discriminated against on the basis of:
Race/Color/National Origin
Age
Disability
Religion/Creed
Sexual Orientation
Sex, including gender identity and gender stereotyping
Other (specify):
When do you believe that the discrimination occurred? LIST DATE(S)
Where within the MassHealth agency do you believe that the discrimination occurred?
Commonwealth of Massachusetts
Executive O ce of Health and Human Services
DCF (03/17)
(continued on back)
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Describe briefl y what happened. How and why do you believe that you have been (or someone else
has been) discriminated against? Please be as specifi c as possible. Attach additional pages as needed.
I understand that by submitting this form I am fi ling a discrimination complaint with the MassHealth
agency. I certify that the information I have provided on this form is true and correct to the best of
my knowledge and belief.
Signature
Date (mm/dd/yyyy)
Do you need special accommodations for us to communicate with you about this complaint?
If so, please specify here:
To submit a complaint, please type or print, sign, and return the completed complaint form package
(including consent form), either by mail, fax, or e-mail to the Section 1557 Compliance Coordinator at
the addresses below.
By Mail: Section 1557 Compliance Coordinator
1 Ashburton Place, 11th Floor
Boston, MA 02108
By Fax: 617-889-7862
By E-mail: Section1557Coordinator@state.ma.us
If you need help submitting a discrimination complaint, please e-mail the Section 1557 Compliance
C
oordinator at Section1557Coordinator@state.ma.us or call 617-573-1704 (TTY: 617-573-1696 for people
who ar
e deaf, hard of hearing, or speech disabled) so that we can assist you.
If you need other information on this website translated or provided in alternative formats, please e-mail
us at Section1557Coordinator@state.ma.us or call us at 617-573-1704 (TTY: 617-573-1696).
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Commonwealth of Massachusetts Discrimination Grievance Form

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Completed 15 May 2020

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