MedStar Request Form

Is this Request for MedStar RADIOLOGY Network *

Yes
No

Please Choose Your Location From the List *

If your location does not appear on this list, please choose “Other” located at the bottom of the list. You will then be able to key in the address.

Please Select the Appropriate Address *

Please Select Appropriate Address *

Please Select the Appropriate Address *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is there a Specific Room or Suite Number? *

If not, please answer “no”

Your Name *

First

Last

Phone Number Where you Can Be Reached If We Have Any Questions *

Your Email Address *

Confirmations will be sent to this email

Are You Requesting American Sign Language (ASL) or A Spoken Foreign Language (such as Spanish, French, Etc) *

ASL
Foreign Language

Please Type the Name of the Language You are Requesting *

Would You Like the Interpreter In-Person or to Join You Virtually? *

In Person
Virtual

Date and Start time of Request (Not Today's Date) *

Date

Time

For Virtual Requests, Please Enter the Link for the Interpreter to Join, or Type "I'd Like SLUSA to Provide the Link" *

Interpreter can join you via any video conferencing app such as telehealth, Zoom, Webex, etc. If you do not want to host the virtual meeting, SLUSA can host using our HIPAA Compliant Zoom account.

Estimated End Time *

Please Describe in General What Type of Appointment

Answers may include, Follow up, New patient Visit, Maternity, Pediatrics, etc.

Patient's Name *

First

Last

Do you have a Preference of the Gender of the Interpreter *

Female
Male
No Preference

Is This Patient Also Blind? *

Yes
No

Patients who are both Deaf and Blind require a specialized tactile interpreter and so we need to know this information in advance.

Please Enter the Routing Code or Purchase Order Number *

This is required for billing. If you do not know the Routing Code, please consult your MedStar Office Manager or Corporate Contact.

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