DHCS Discrimination Complaint Form - State of California 2026

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The document is a Civil Rights Compliance Review form from the California Department of Health Care Services, designed for agencies and facilities to report on their adherence to civil rights laws, including Title VI, Section 504, and the ADA. It collects information about the agency's demographics, services for disabled individuals, bilingual staff availability, admission policies regarding HIV/AIDS patients, and overall compliance with non-discrimination practices.

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Click ‘Get Form’ to open the DHCS Discrimination Complaint Form in our editor.
Begin by filling in the agency or facility name, provider number, address, county, and ZIP code in the designated fields. Ensure accuracy as this information is crucial for identification.
Next, provide details about the administrator and contact numbers. This section helps establish a point of contact for any follow-up inquiries.
Indicate the type of agency or facility by selecting from the provided options. This classification aids in understanding the context of your complaint.
Complete the sections regarding bilingual services and services for disabled employees/residents. Be thorough in detailing available resources and procedures.
Finally, review all entries for completeness and accuracy before submitting. Use our platform’s tools to sign and distribute your completed form easily.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (168 Votes)
2011	4 Satisfied (57 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long do you have to file a discrimination complaint in California?

In general, a complaint of employment discrimination must be filed within three years from the date an alleged discriminatory act occurred. You must file a complaint with CRD even if you wish to file a case directly in court.

How do I file a complaint with the state of California?

File a complaint with government or consumer programs File a complaint with your local consumer protection office. Notify the Better Business Bureau (BBB) in your area about your problem. The BBB tries to resolve complaints against companies. Report scams and suspicious communications to the Federal Trade Commission.

What are the requirements for a complaint?

In order to file a complaint, you must pay a filing fee that is currently $405. You may pay the filing fee in-person by cash, check (made out to Clerk, U.S. District Court), money order, or credit card. If mailing your complaint, please send in a check.

How to complain about racial discrimination?

Equality Advisory Support Service (EASS) If you have experienced discrimination, you can get help from the EASS discrimination helpline. You can find useful information about discrimination on the EHRC website at .equalityhumanrights.com.

How do I file a complaint about discrimination in California?

Using our online California Civil Rights System (CCRS). Create an account on the Cal Civil Rights System for yourself. All you need is a valid email address and a phone number. Once you have an account, call 800-884-1684. Our staff will associate your account with the complaint. Log into your CCRS account.

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How to file a complaint with the state of California?

If you would like to file a complaint with the California Attorney General, here is how: By Phone: 916-322-3360. Toll-Free Phone Number: 1-800-952-5225. By Mail: Download, fill out, and mail this form to P.O Box 944255, Sacramento 94244.

What is the best way to file a complaint?

A plaintiff starts a civil action by filing a pleading called a complaint. A complaint must state all of the plaintiffs claims against the defendant, and must also specify what remedy the plaintiff is seeking. After receiving the complaint, the defendant must respond with an answer.