ACA Statement

Gramercy Surgery Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Gramercy Surgery Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

 

Gramercy Surgery Center:

  • 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, other 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 Gramercy Surgery Center Compliance Coordinator, 212-254-3570.

 

If you believe that Gramercy Surgery Center 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:

Compliance Coordinator

Gramercy Surgery Center, 380 Second Avenue, 10th Fl., Suite 1000, New York NY 10010

TEL: 1-212-1254-3570; FAX: 1-212-254-3572

Email: sabrinag@gramercysurgery.com

 

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Gramercy Surgery Center’s Compliance Coordinator 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

 

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

 

ATTENTION: Language assistance services, free of charge, are available to you.  

Call 1-212-254-3570 (TTY: 1-212-254-3570).

 

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-212-254-3570 (TTY: 1-212-254-3570).

 

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-212-254-3570 (TTY: 1-212-254-3570).

 

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-212-254-3570 (телетайп:1-212-254-3570).

 

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-212-254-3570 (TTY: 1-212-254-3570).

 

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-212-254-3570 (TTY: 1-212-254-3570)번으로 전화해 주십시오

 

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-212-254-3570 (TTY: 1-212-254-3570).

 

אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט  1-212-254-3570(1-212-254-3570 TTY)

 

লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন েফান করন ১-212-254-3570) (TTY: ১-212-254-3570)।

 

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-212-254-3570 (TTY: 1-212-254-3570).

 

ملحوظة:  إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان.  اتصل برقم 3570-254-212-1

(رقمهاتف الصم والبكم:3570-254-212-1).

 

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-212-254-3570 (TTY: 1-212-254-3570).

 

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-212-254-3570 (TTY: 1-212-254-3570).

 

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-212-254-3570 (TTY: 1-212-254-3570).

 



Pre-Admission Testing Questionnaire

  • Part 1


  • Part 2









  • Part 3



  • Part 4


  • Please describe your regular physical activities (select all that apply):



  • Light Intensity Activities (< 3)


  • Moderate Intensity Activities (3 to 6)


  • Vigorous Intensity Activities (> 6)