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Interpretation Request Form

"*" indicates required fields

Type of Interpretation Service*

Select the Industry you require Interpretation Services for*

Will you be using third-party billing?*

Please use Schedule Interpreter to complete your request.

Request Access

Need Help? Email: lbsupport@thelanguagebank.org

Your Name*

First Last

Name of Organization*

Email*

Email Confirm Email

Phone*

Comments

How did you hear about us?*

Company to be Billed:*

Department Requesting Services:*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Accounting Manager Information

Name of Accounting Manager:*

First Last

Accounting Manager Email*

Accounting Manager Phone*

Accounting Manager Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Information

Name of Client:*

First Last

Case ID Number

PO Number

Date of Birth:*

MM slash DD slash YYYY

Language:*

Client Description - Age:*

Adult

Child

Client Description - Gender:

Does the client have a preferred interpreter?:

Appointment

Date of Appointment:*

MM slash DD slash YYYY

Appointment Location/Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Appointment Start Time:*

Hours

Minutes

AM/PM

Appointment End Time:*

Hours

Minutes

AM/PM

Provider Name; Dept; Telephone:*

Purpose:*

Client Phone (Optional):

Please provide a client phone number if you want our interpreter to place a reminder call to your client. Kindly note that this is just a courtesy call:

Please use the space below to inform us if the patient or customer in need of services is suspected of having, or known to have, any infectious diseases, including viruses:*

If not, please write "none" or "N/A."

Will this appointment take place Over the Phone, use MS Teams, Doxy.me, or any other remote meeting technology?:*

Yes

If you answered "yes" to the above question, then please provide the meeting URL, meeting ID, Password (if required), and phone number (if needed):

Would you like to use our online scheduling platform to submit future requests for interpreters:*

Yes

Please send us more information about the scheduling platform

Language Bank Interpreter to provide courtesy reminder call:

Yes

(Please note that this is ONLY courtesy reminder call and patient/client may still not show up to his/her appointment)

If a patient/client does not answer the phone and his answering machine/voice mail picks up a call or family member answers the phone, can interpreter provide/give full appointment info (date, time, location, name of hospital/clinic/department, providers name) on patient/client voice message or give this info to patient/client’s family member?:*

Yes

Agreement*

Yes, I agree

By submitting this request, you and your agency agree to the following Language Bank terms: The requesting agency agrees to pay Language Bank a 2-hour minimum. Additional time will be assessed in 30 minutes increments, plus interpreter’s travel time and mileage expense. In case of cancelled or rescheduled appointments by the requesting agency with less than 24 Business hours (48 Business hours for Deaf and Hard of Hearing) notice prior to service start-time, or in the case of no-shows or late arrival beyond 30 minutes, the requesting agency is responsible for full payment.

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"*" indicates required fields

Name*

First Last

Email*

Address*

Phone*

Date of Appointment*

MM slash DD slash YYYY

Message*

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Translation Request Form

Requester Information:

Name(Required)

First Last

Phone Number(Required)

Email Address(Required)

How did you hear about us?

Translation Request Information:

Language(s) Requested:(Required)

Deadline Date:

MM slash DD slash YYYY

Is your request URGENT?

Yes

Do you need your Translation Notarized?

Yes

Additional Comments:

Billing Contact Information:

Company:

Name of Billing Contact:(Required)

First Last

Billing Contact Phone Number:(Required)

Billing Contact Email Address:(Required)

Billing Contact Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Industry:

Consent

I agree to the privacy policy.

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Contact Us

Interpretation Request Form

Login

Request Access

Accounting Manager Information

Client Information

Appointment

Let's get in touch

Translation Request Form

Requester Information:

Translation Request Information:

Billing Contact Information: