Hhs 690 Form – Fill Out and Use This PDF

Updated: Oct 31, 2026

The HHS 690 form serves as an Assurance of Compliance with multiple critical federal laws, specifically targeting the realms of civil rights, rehabilitation, education amendments, age discrimination, patient protection, and conscience and anti-discrimination laws within the U.S. Department of Health and Human Services (HHS). This form, essential for entities seeking federal financial assistance from HHS, legally binds the applicant to adhere strictly to guidelines ensuring no discrimination on the grounds of race, color, national origin, sex, age, or disability, in line with specific acts and amendments. Should you need to affirm your compliance with these stipulations, consider filling out the form by clicking the button below.

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Hhs 690 Form PDF Details

The HHS 690 form serves as a pivotal document for entities seeking Federal financial assistance from the U.S. Department of Health and Human Services (HHS), encapsulating their commitment to adhere to a suite of civil rights and non-discrimination laws. By submitting this form, applicants affirm their compliance with landmark legislations including the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Education Amendments of 1972 (Title IX), the Age Discrimination Act of 1975, Section 1557 of the Patient Protection and Affordable Care Act, and several Federal conscience and anti-discrimination laws. These laws collectively ensure that no person in the United States will be excluded from, denied the benefits of, or subjected to discrimination under any program or activity receiving Federal financial support from HHS on grounds of race, color, national origin, sex, age, or disability. Furthermore, the form acknowledges the rights protected under various Federal conscience and anti-discrimination laws, emphasizing the prevention of coercion and discrimination. Compliance with the assurances provided in the HHS 690 form is not only a precondition for receiving Federal financial aid but also serves as a binding agreement enforceable through judicial action, ensuring the provision remains effective for the duration of the aid. This assurance stands as a testament to an applicant’s dedication to upholding fundamental rights and equal treatment across all federally supported health programs and activities.

Question	Answer
Form Name	Hhs 690 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Assurance of Compliance. Form 690

How to Fill Out HHS Form 690

HHS Form 690 at a glance

What it is: Assurance of Compliance: the Applicant provides this assurance for the purpose of obtaining Federal grants, loans, contracts, property, discounts or other Federal financial assistance from the U.S. Department of Health and Human Services.

Who signs: The person whose signature appears on the Signature of Authorized Official line is authorized to sign this assurance and commit the Applicant to the provisions of this assurance.

Where and when to file: Please mail form to: U.S. Department of Health & Human Services Office for Civil Rights 200 Independence Ave., S. W. Room 509F Washington, D.C. 20201

A filled-in HHS Form 690 example: a clinic's official signs the assurance

HHS Form 690 example filled out, example: a clinic's official signs the assurance — A clinic's authorized official signs the Assurance of Compliance. The clinic applies for Federal financial assistance from the U.S. Department of Health and Human Services. The picture shows the filled form, and its names and figures are sample values.

How to fill out HHS Form 690, box by box

Signature, date and name of the authorized official

Sign on the Signature of Authorized Official line, enter the Name and Title of Authorized Official (please print or type) and the Date.

Agency and address

Enter the Name of Agency Receiving/Requesting Funding, the Street Address and the City, State, Zip Code.

More rules for HHS Form 690

Title VI of the Civil Rights Act of 1964, as amended (codified at 42 U.S.C. § 2000d et seq.), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 80), to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.

Section 504 of the Rehabilitation Act of 1973, as amended (codified at 29 U.S.C. § 794), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 84), to the end that, in accordance with Section 504 of that Act and the Regulation, no otherwise qualified individual with a disability in the United States shall, solely by reason of her or his disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.

Title IX of the Education Amendments of 1972, as amended (codified at 20 U.S.C. § 1681 et seq.), and all requirements imposed by or pursuant tot he Regulation of the Department of Health and Human Services (45 C.F.R. Part 86), to the end that, in accordance with Title IX and the Regulation, no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any education program or activity for which the Applicant receives Federal financial assistance from the Department.

The Age Discrimination Act of 1975, as amended (codified at 42 U.S.C. § 6101 et seq.), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 91), to the end that, in accordance with the Act and the Regulation, no person in the United States shall, on the basis of age, be denied the benefits of, be excluded from participation in, or be subjected to discrimination under any program or activity for which the Applicant receives Federal financial assistance from the Department.

Section 1557 of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18116), and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 92), to the end that, in accordance with Section 1557 and the Regulation, no person in the United States shall, on the ground of race, color, national origin, sex, age, or disability be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any health program or activity for which the Applicant receives Federal financial assistance from the Department.

As applicable, the Church Amendments, as amended (codified at 42 U.S.C. § 300a-7), the Coats-Snowe Amendment (codified at 42 U.S.C. § 238n), the Weldon Amendment (e.g., Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2019, Div. 27, 2019)), Section 1553 of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18113), and Section 1303(b)(4) of the Patient Protection and Affordable Care Act, as amended (codified at 42 U.S.C. § 18023(b)(4)), and other Federal conscience and anti-discrimination laws, including but not limited to those listed at https://www.hhs.gov/conscience/conscience-protections, and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 C.F.R. Part 88), to the end that the rights of conscience are protected and associated discrimination and coercion are prohibited, in any program or activity for which the Applicant receives Federal financial assistance or other Federal funds from the Department for which the Federal conscience and anti-discrimination laws and 45 C.F.R. Part 88 apply.

The Applicant agrees that compliance with this assurance constitutes a condition of continued receipt of Federal financial assistance, and that it is binding upon the Applicant, its successors, transferees and assignees for the period during which such assistance is provided.

If any real property or structure thereon is provided or improved with the aid of Federal financial assistance extended to the Applicant by the Department, this assurance shall obligate the Applicant, or in the case of any transfer of such property, any transferee, for the period during which the real property or structure is used for a purpose for which the Federal financial assistance is extended or for another purpose involving the provision of similar services or benefits.

If any personal property is so provided, this assurance shall obligate the Applicant for the period during which it retains ownership or possession of the property.

The Applicant further recognizes and agrees that the United States shall have the right to seek judicial enforcement of this assurance.

Common questions about HHS Form 690

Where do I file it?

The Applicant may provide this assurance via the U.S. Department of Health and Human Services' Assurance of Compliance online portal at https://ocrportal.hhs.gov/ocr/aoc/instruction.jsf in lieu of mailing it to the address provided.

Sources

[1] HHS Form 690 (Last updated 11/2019), Assurance of Compliance, U.S. Department of Health and Human Services (the Official source link on this page).