Some CCCS Interpreter Services Team Members

Interpreter Services: request service

PLEASE NOTE: clients should call CCCS to follow up on any next-day requests.

Part I - Contact Information (* required in BOLD)

Organization:

Billing Name:

Billing Address:

State:

Zip:

Contact Name:

Phone Number:

Fax Number:

E-Mail:

Comment:

Part II - Appointment Information

Client/Patient Name:

Demographic Information (Please check all that apply):

Male			Female
Adult			Child

Language:

If other, please enter source language:

Date of Appointment:

Appointment Start-Time:

Appointment End-Time:

Location/Address:

Provider:

Department:

Provider Phone Number:

Logistical Information (Please answer the following questions):

1. Does the interpreter need to call the client?

2. If yes, the interpreter should call the client at Phone Number:

And should:	Schedule an appointment with the client.
	Remind the client of the scheduled appointment 24 hours in advance.

3. If the client has previously worked with a CCSS, Inc. Interpreter, would the client prefer to work with the same Interpreter?

4. If yes, please provide the name of the Interpreter:

PLEASE NOTE: clients should call CCCS to follow up on any next-day requests.