SIGN LANGUAGE INTERPRETING SERVICES REQUEST FORM

SIGN LANGUAGE INTERPRETING SERVICES REQUEST FORM

ALL DATA SHARED IN THIS FORM FOLLOWS HIPAA COMPLIANCE GUIDELINES.

FOR URGENT OR EMERGENCY REQUESTS, AFTER 5 PM, ON WEEKENDS, OR HOLIDAYS, DO NOT FILL OUT THE FORM.

INSTEAD, CONTACT THE AFTER-HOURS STAFF AT 352-598-2755.

* Please note that this is not a confirmation of an appointment. By submitting this form you understand that this is to request availability. Our team will contact you to inform if we have availability for your appointment.

Client/Patient Information

APPOINTMENT TYPE*

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NATURE OF MEDICAL APPOINTMENT*

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NATURE OF LEGAL APPOINTMENT*

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NATURE OF APPOINTMENT*

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INTERPRETER TYPE OR PREFERRED INTERPRETER (IF AVAILABLE)

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CLIENT/PATIENT NAME*

DOB / MRN*

Appointment Information

NAME OF THE FACILITY/CLINIC FOR THE INTERPRETING SERVICE*

ADDRESS OF APPOINTMENT (Please include details: suite/room/floor, etc. #)*

CITY OF APPOINTMENT*

ZIPCODE*

LOCATION PHONE NUMBER*

Phone

EXTENSION

APPOINTMENT DATE*

START TIME (EST)*

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APPOINTMENT LENGTH*

APPOINTMENT WITH (ie.: provider, etc.)

DOES THIS APPOINTMENT HAVE MULTIPLE START TIMES, AND/OR LOCATIONS?*

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PLEASE PROVIDE THE MULTIPLE START TIMES, AND/OR LOCATIONS*

ADDITIONAL APPOINTMENT DETAILS (ie.: remote/virtual link)

REQUESTED BY*

E-MAIL - FOR CONFIRMATIONS*

*Emails will not contain Personally Identifiable Information.

Billing Information

BUSINESS NAME

BILLING PHONE

Phone

BILLING ADDRESS

BILLING CITY

BILLING STATE

BILLING ZIPCODE

PO NUMBER

DEPT. ID

AUTHORIZED BY*

TERMS AND CONDITIONS: ARE YOU A NEW OR ESTABLISHED CUSTOMER?*

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