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FORMULAIRE DE DEMANDE D’INTERPRETE

 

Veuillez utiliser ce Formulaire de Demande Enligne pour demander un interprète. Si vous désirez, vous pouvez nous faxer votre demander d’interprète au (704.365.2969)

 

Si vous avez des questions, vous pouvez contacter le département de traduction au 704-307-2332 / 704.307.2333 ou 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]
Appointment Date:                Appointment Time:
Pick Up [1]
Pickup Time:
Location Name:
Address:
City, State, Zip Code:
Telephone:  Ext. 
Destination [1]
Location Name:
Address:
City, State, Zip Code:
Contact:
Telephone:  Ext. 
Appointment [2]
Appointment Date:                Appointment Time:
Pick Up [2]
Pickup Time:
Location Name:
Address:
City, State, Zip Code:
Telephone:  Ext. 
Destination [2]
Location Name:
Address:
City, State, Zip Code:
Contact:
Telephone:  Ext.