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INTERPRETER REQUEST FORM

 

Please use this Online Order Form to request an Interpreter. If you wish, you can fax us your interpreter request at  (704.307.2333)

 

If you have any questions, please, contact the Interpreting Department at 1.866.978.4619 or interpreting@ghusa.net.

 

Referral Source Information
Name:
Company:
Title:
Address:
City, State, Zip Code:
Telephone:  Ext.  
Fax:
E-mail:
 
 
Billing Information
Name:
Company:
Address:
City, State, Zip Code:
Adjuster:
E-mail:
Telephone:  Ext. 
Fax:
Claim Number:
Authorization Number:
  Check to copy referral source information for billing information. 
Injured Worker Information
Name:
SSN:
Address:
City, State, Zip Code:
Telephone:  
Which Language:
Employer:
Injury Date:
Required Services
 
Type of transportation required by patient:  
  Check if Transportation is needed. 

 

Comment :    
 
Appointment [1]
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Pick Up [1]
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Location Name:
Address:
City, State, Zip Code:
Telephone:  Ext. 
Destination [1]
Location Name:
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Contact:
Telephone:  Ext. 
Appointment [2]
Appointment Date:                Appointment Time:
Pick Up [2]
Pickup Time:
Location Name:
Address:
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Telephone:  Ext. 
Destination [2]
Location Name:
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Contact:
Telephone:  Ext.