Medicaid Non-Discrimination & Contribution Form

Medicaid Non-Discrimination & Contribution Form

Northeast Missouri Area Agency on Aging
Client Name:

First NameLast Name
Medicaid Number (DCN): blanks
Your home-delivered meal is now being paid for by the State of Missouri’s Medicaid program. As long as you remain eligible for the Medicaid program, we will not ask for or accept a voluntary contribution for your meal.
Non-Discrimination Policy Statement

It is the Policy of Northeast Missouri Area Agency on Aging to provide services to all persons without regard to race, color, national origin, religion, gender, age, sexual orientation or disability. No person shall be excluded from participation in, be denied the benefits of any services, or be subject to discrimination because of race, color, national origin, religion, gender, age, sexual orientation or disability.
Complaint Procedure

If you believe you have been denied a benefit or services because of your race, color, national origin, religion, gender, age, or disability, you may file a Complaint of Discrimination with the Northeast Missouri Area Agency on Aging, either verbally or in writing.

Northeast Missouri Area Agency on Aging

2815 N Baltimore St, Kirksville, MO 63501

(660) 665-4682 or (800) 664-6338
If you choose to file your complaint in writing, please include your name, address, telephone number, and a brief description of what occurred that led you to believe you were discriminated against.
You may also file a Complaint of Discrimination by contacting either of the external agencies listed below:

Department of Social Services	Department of Health and Human Services
Office for Civil Rights	Office for Civil Rights
P.O. Box 1527	601 East 12th Street
Jefferson City, MO 65102	Kansas City, MO 64106
(800) 776-8014	(816) 426-7277

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