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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 efax@thelanguagebanc.com. 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/<br>

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Interpreter Worksheet for Interpreting Solutions to Patients

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  1. 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 efax@thelanguagebanc.com 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: __________________________________ Gender: Female  Male DOB: _________________________ MR#: ________________________________ Address: __________________________________________________ City: ______________________________ State: ________ Zip Code: _____________________ Phone: (_______) _______ - ___________ Insurance: Blue+  Health Partners  UCare  None  Other: Specify ______________________ Member ID #: _________________________________ MUST BE COMPLETED by Medical Provider/Staff: Date: __________________________ Start Time: ____________ AM / PM End Time: ____________ AM / PM If more than 2 hours, how many? hrsREMINDER: 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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