DHCC Interpreter Request - Clinical Care Associates (CCA)

This interpreter request form is ONLY for Clinical Care Associates (CCA) customer use.

Requester Contact Information

Clinical Care Associates (CCA) Employee

CCA Employee First name

CCA Employee Last name

Clinical Care Associates (CCA) Employee Email

Clinical Care Associates (CCA) Employee Phone Number

Date of Service

Requested Time for Interpreter Arrival

Time

HoursMinutes

Actual Start Time

Time

HoursMinutes

End Time

Time

HoursMinutes

Type of Service

In- Person ASL Interpreting

Virtual ASL Interpreting (please provide link)

Remote Captioning (CART)

Clinic/Department

EPIC ID

Building Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Suite-Floor Number

Assignment Details

Deaf/Hard-of-Hearing Consumer First name

Deaf/Hard-of-Hearing Consumer Last name

DOB of Patient

Month

Day

Year

Interpreter Check-In Process For Entering Your Facility

Security, Parking, etc.

Clinical Care Associates (CCA) Contact For Day of Appt Name

Onsite Contact First name

Onsite Contact Last name

Clinical Care Associates (CCA) Contact For Day of Appt Phone Number

Name of Medical Professional

Reason for Visit / Type of Appointment

Additional Information

Names of Preferred Interpreter, if requested

DHCC Interpreter Request - Clinical Care Associates (CCA)

Requester Contact Information

Assignment Details

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