MedStar Request Form – Language Interpretation and Translation Services

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.

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) *

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

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

Date

Time

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 *

Is This Patient Also Blind? *

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.