*Today’s Date: __/__/__            *Your Name: ________________________________________________

 

*Your Phone #: (617) 726-6966                            Your Fax #: (617) 726-3253

 

*Your Agency:             Massachusetts General Hospital                                             

                                                                                                (Boston or Health Center)

*Date (s) of Assignment: ______________________________________________________________

 

*Beginning Time of Assignment: ______________        End Time of Assignment: ______________

 

 

*Location/Address::  ____________________________________________________

                                    (include bldg., unit, floor, and room #)
*Clinic/Department: ________________________             *Provider: _____________________     

 

*Phone number on-site:(        ) ________________                        *Contact Person in the department:_______________

*Type of Appointment/Description:  _________________________________________

 

*MRN:_______________________________

 

*Name of Patient:_______________________                        Date of Birth: __________________

 

Communication Preference, if known:_________________________________________

                                (ASL, Signed English, tactile, etc.)

 

Interpreter Name:_________________________                        Outcome:_____________________

Requested Interpreters: (unless otherwise specified by requester,

Referral Service will also contact other qualified interpreters if

requested interpreters are unavailable)

 

Other information: _______________________________________________________

 

*Billing Information: (Request will NOT be processed without billing information.)

Contact Person: Phyllis Robertson            Phone number: (617) 726-2605

Address:                       Massachusetts General Hospital

                        Department of Social Services - Lobby Wang

                                    55 Fruit St.  Boston, Ma 02114

TO BE FILLED OUT BY THE CONTACT PERSON AT THE INTERPRETER SERVICES DEPARTMENT

Signature: ________________________                                                Date: ____________________________

 

Print Name: ______________________                            Title: ____________________________

 

COMMISSION USE ONLY

AREA:                                                                                   JOB:

REC’D BY:                                                                             ENTERED BY: