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Interpreter Worksheet For Interpreting Solutions To Patients

The importance of the interpreter services to patients lives, please fill the Interpreter Worksheet & must be submit completed worksheet within 48 HOURS. After completing this worksheet fax to 1-800-686-6315 or email to [email protected]. The Language Banc gives quality interpreting solutions that ensure clinicians provide their limited English proficient, Deaf and hard of hearing patients with access to the highest quality healthcare. Visit here: https://www.thelanguagebanc.com/

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Steven Moore
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193 views

Interpreter Worksheet For Interpreting Solutions To Patients

The importance of the interpreter services to patients lives, please fill the Interpreter Worksheet & must be submit completed worksheet within 48 HOURS. After completing this worksheet fax to 1-800-686-6315 or email to [email protected]. The Language Banc gives quality interpreting solutions that ensure clinicians provide their limited English proficient, Deaf and hard of hearing patients with access to the highest quality healthcare. Visit here: https://www.thelanguagebanc.com/

Uploaded by

Steven Moore
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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1625 Park Ave

Minneapolis, MN 55404
Office: 612.588.9410
24-hr Phone: 612.695.6008

Interpreter Worksheet
Interpreters must submit completed worksheet WITHIN 48 HOURS
Please fax worksheets to 1-800-686-6315 or email to [email protected]
Interpreter ID #: ______ ___________ MDH Roster ID #: ______ ___________

Interpreter Name: (print clearly)_ ______ ___________ ___ Language: _____________________ ___

Interpreter Signature: ___________________ _____ __ Date: _________________________

Appointment Date:_____________________________ Appointment Time:_________________ AM / PM

Clinic Name: ______________________________________ Department: ________________________________


 Inpatient  Dialysis
Address: __________________________________________________ City: _____________________________

State: ________ Zip Code: _____________________ Phone: (_______) _______ - ___________

Name of Provider: ___________________________________________________ ____

PATIENT/CLIENT:

Last Name: _____________________________________ First Name: __________________________________

DOB: _________________________ Gender:  Female  Male MR#: ________________________________

Address: __________________________________________________ City: ______________________________

State: ________ Zip Code: _____________________ Phone: (_______) _______ - ___________

Insurance:  Blue+  Health Partners  UCare  None


Member ID #: _________________________________
 Other: Specify ______________________

MUST BE COMPLETED by Medical Provider/Staff:


Date: __________________________ Start Time: ____________ AM / PM End Time: ____________ AM / PM

If more than 2 hours, how many? hrs REMINDER: Interpreters cannot work for more than 8 hours.
Appointment Status (circle one): Completed Cancellation Same Day Cancellation Patient No Show
Overall quality of interpreter: Excellent Average Poor (please specify)
Comments: ________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Staff Name: _ ______________ _ Staff Signature: _____ __ _____________ Date: _______________

Office Use Only:


 B+  HP  UC  Clinic

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