Provider On-Site Interpreter Request Form

Language Needed for Spoken Interpretation

Please indicate if the communication mode is anything other than ASL (e.g., PSE, Signed English, Oral, Tactile, etc.)

If a trilingual interpreter is required, please indicate the third language

Preference of Interpreter Female required (may limit availability of interpreters) Female preferred, but not required Male required (may limit availability of interpreters) Male preferred, but not required No preference

Person Needing Interpreter:

Full Name *

Member ID *

This person is a: * Member Prospective Member Associate

Phone Number *

Alternative phone number

Email Address

Appointment Details:

Date *

Time *

Estimated Duration *

Appointment Type (e.g., annual physical, physical therapy, surgery) *

Facility Name (name of hospital/clinic) *

Provider Name (name of the doctor/therapist)

Provider’s ID / NPI Number

Appointment Street Address

Appointment Building/Suite/Room/Floor

City/State/Zip *

On-Site Contact Name

On-Site Phone

Additional location details (e.g., parking or other arrival information to assist the interpreter in arriving on site)

We cannot guarantee an interpreter if the request is received less than 5 business days before the appointment. Requests for interpreters cannot be made more than 30 days in advance of the scheduled appointment.

Quality care is a team effort. Thank you for playing a starring role!

Last Updated: 08/26/2024