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FORMULARIO PARA PEDIR LOS SERVICIOS DE INTERPRETACIÓN

 

Por favor utilice este formulario para pedir a un interprete. Si usted quiere, también puede enviarnos un fax para solicitar a un interprete al (704.365.2969)

 

Si usted tiene alguna pregunta, por favor póngase en contacto con el departamento de interpretación llamando al 704-651.5711 / 704.651.5710 o 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. 

 

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Appointment [1]
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Destination [1]
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Appointment [2]
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