Interpreter Request Form

Interpreter Request Form

Please fill out this form to request an interpreter for translation needs. We require four business days advance notice to schedule an interpreter. If you need to cancel your interpreter after the appointment has been scheduled, we require two business days advance notice.

Member ID number (a state ID):(Required)

Member Name(Required)

First Last

Date of Appointment(Required)

Date must be 72 business hours (3 days) from today to allow time for scheduling.

Time of Appointment(Required)

Duration of Appointment(Required)

Language(Required)

Preferred Interpreter(Required)

Preferrered Gender(Required)

Language(Required)

Requestor Name(Required)

Requestor Email Address(Required)

Interpretation type(Required)

Meeting ID(Required)

Meeting Passcode(Required)

Telehealth URL(Required)

Name of Appointment Location(Required)

Appointment address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you the member or the provider?(Required)

Appointment department, what floor/building name(Required)

Provider's contact person's name(Required)

Provider's contact person's phone number(Required)

If you have any questions, please contact the customer service team at 800-511-5010.