Fillable Interpreter Request Form Member Information Please complete and (Cook Children's Health Plan)

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Interpreter Request Form Member Information Please complete and (Cook Children's Health Plan)

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Country of origin: US
File type: PDF

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Interpreter
Request Form
Please complete and email form to CCHPInterpreterRequest@cookchildrens.org. Requests
must be sent 3-4 days in advance.
Today’s Date ______________
Member Information
First Name: ____________________________ Last Name: ____________________________
ID Number: __________________________________________________________________
Street Address: _______________________________________________________________
City: ___________________________ State: ____________ Zip: ______________________
Contact Name: __________________________ Contact Phone: ________________________
Provider Information
Provider Name: _______________________________________________________________
Street Address: _______________________________________________________________
City: ___________________________ State: _____________ Zip: ______________________
Phone: ________________________________ Fax: _________________________________
Type of Interpreter: ❏ Office ❏ Home ❏ Virtual
❏ Other _______________________________________________________
Requester Contact Information
Name of person filling out form: ___________________________________________________
Contact Phone: _________________ Contact Email: _________________________________
❏ Member ❏ Provider ❏ Subscriber/LAR
Appointment Information
Appointment Date: __________________ Appointment Time: ___________________________
Requested Language: __________________________________________________________
How long is the appointment expected to last? _______________________________________
Appointment Reason: __________________________________________________________
Additional Instructions: _________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
RevNov20
05072020CR
801 Seventh Avenue Box 2488
Fort Worth, Texas 76113-2488
cookchp.org
SUBMIT REQUEST
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Interpreter Request Form Member Information Please complete and (Cook Children's Health Plan)

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Completed 7 May 2021

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