Request For Sign Language Interpreter - Dshs
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1
2Request for Sign Language Interpreter
COMPLETED BY REQUESTER
1. PERSON REQUESTING INTERPRETER FOR AN APPOINTMENT
2. DATE OF REQUEST
3. TELEPHONE NUMBER (INCLUDE AREA CODE)
4. AGENCY
5. DSHS ADMINISTRATION/DIVISION OR SERVICE/MEDICAL PROVIDER
DSHS
Other (specify):
6. BILLING ADDRESS
7. INTERPRETER REFERRAL AGENCY (IF APPLICABLE)
1. APPOINTMENT DATE
2. SCHEDULED START TIME
3. SCHEDULED END TIME
AM
PM
AM
PM
4. APPOINTMENT ADDRESS (WHERE APPOINTMENT WILL BE HELD)
5. BUILDING
FLOOR
ROOM
6. APPOINTMENT CONTACT (IF OTHER THAN REQUESTER)
7. CLIENT/EMPLOYEE NAME (OR DASA APPROVAL NUMBER)
CONTACT TELEPHONE NUMBER
GENDER
Male
Female
8. CLIENT IDENTIFICATION NUMBER
PIC CODE (ON DSHS MEDICAL IDENTIFICATION CARD)
OR
9. CLIENT COMMUNICATION PREFERENCE
DEAF BLIND
American Sign Language
Pidgin Signed English
Signed Exact English
Oral
Tactile OR
Close Up
Minimal Language Skills (QDI/CDI)
Other (specify):
10. TYPE OF APPOINTMENT SETTING
11. Specific interpreter requested:
Yes
No
If yes, name of interpreter requested:
COMPLETED BY INTERPRETER REFERRAL AGENCY/CONTRACTOR
1. INTERPRETER NAME
CERTIFICATION LEVEL
ADDITIONAL INTERPRETER(S) (IF APPLICABLE)
2. APPOINTMENT
3. CONFIRMATION NOTIFIED TO REQUESTER WITHIN 48 HOURS?
4. TRACKING NUMBER
Filled
Unfilled
Yes
No
COMPLETED BY INTERPRETER
1. ADDRESS OF ORGIN (HOME PLACE OF BUSINESS, PREVIOUS APPOINTMENT)
2. ADDRESS OF DESTINATION
3. CHECK IF DESTINATION IS
Home
Place of business
For payment, address cannot be to a subsequent appointment.
4. SERVICE
5. MILEAGE
Start time:
Mileage to appointment:
End time:
Mileage from appointment (if applicable):
Total billing time:
Total mileage:
6. Other fees incurred (parking, ferry, etc.):
COMPLETED AT TIME OF APPONTMENT BY INTERPRETER AND STATE/PROVIDER EMPLOYEE
SERVICE:
1. Was this service completed?
Yes, complete VERIFICATION section below
No, check the correct reason why this service was not completed:
CANCELLATION INFORMATION
NO SHOW BY:
CANCELLATION BY:
(REQUIRED FOR CANCELLATIONS):
Client
Client
Date:
DSHS/State Employee
DSHS/State Employee
Time:
AM
PM
Service/Medical Provider
Service/Medical Provider
Name of person cancelling:
Interpreter
Interpreter
Other (specify):
Other (specify):
* Only cancellations with less that 48 hours
notice are billable
VERIFICATION:
2. INTERPRETER’S SIGNATURE
DATE
DO NOT SIGN unless sections above are completed. Be sure to check for accuracy and for the interpreter’s signature above. Interpreter
signature not required if cancelled. Use the comments section as needed.
3. SIGNATURE OF STATE OR PROVIDER EMPLOYEE CONFIRMING SERVICE DELIVERY
DATE
PRINT NAME HERE
TITLE/POSITION
4. COMMENTS
DSHS 17-123A (REV. 05/2007)
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