Interpretation Form
CBH provider requesting interpretation:
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Date of request
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mm/dd/yyyy
Name of CBH member:
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Member CIS number
Type of Service
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Date (s)of appointment:
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Beginning and End times of appointment:
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Location of Appt
Address of appointment (If app virtual put N/A)
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Telehealth / Zoom link or phone number
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Contact person/phone# if interpreter has any issue
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Requestors Email
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Requestors phone
*
Language needed:
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Preferred interpreter
Name and relationship if not for member:
*
*
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