Request for ASL Interpreting Services

Request for ASL Interpreting Services
Which Area: West Tennessee & Surrounding Areas, Middle Tennessee & Surrounding Areas or East Tennessee & Surrounding Areas
Please note that BridgeesDHH provides services throughout Tennessee and surrounding states. The designations above reference the physical offices from which interpreters work.
Requester Name

First NameLast Name
Company/Business/Organization
Requester Phone*

Area CodePhone Number
Requester Email*
example@example.com
Confirm Requester Email*
example@example.com
Requester Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you used our services before or do not need to update your billing information, please choose NO/BILLING UPDATE.*
Billing Contact*

First NameLast Name
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Phone Number

Area CodePhone Number
Billing Email
example@example.com
Bill information is mandatory unless this box is checked, indicating that invoices can be sent to the requester.
PO or Routing Code Number
Can the invoice be emailed?*
Type of Services Requested*
Service Context*
Name of Deaf Client*

First NameLast Name
Date of Appointment*

MonthDayYear
Date
Start Time Interpreter Needed*

:HourMinutesAM/PM Option
End Time Interpreter Needed*

:HourMinutesAM/PM Option
Service Location*
Name of school other location where services will be provided.
Timezone
Exact Address of Appointment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parking | Driving Instructions*
On-Site Contact*

First NameLast Name
On-Site Contact Number*

Area CodePhone Number
Please List ALL Individuals to be Present at Appointment and their Roles*
If Requested, Name of Preferred Interpreter
Briefly describe the setting and what will be taking placewhen the interpreter arrives so that the interpreter may prepare for the assignment.
Is there anything else we need to know?*
dress requirements, event to be videotaped, etc., agenda or program
Please click here to review our policies.

Our current rate sheets are available by request. Please contact interpreting@bridgesfordeafandhh.org.
Please click here and sign below to acknowledge you have reviewed and agreed to our policies. We cannot proceed with services without this acknowledgement. Please note that our policies include a cancellation/rescheduling policy because we are reserving and guaranteeing payment for the service provider's time. This policy applies regardless of whether the Consumer or Request cancels the job.*

click here
By signing below, you specifically acknowledge an understanding that all requests carry a 48-business hour cancellation policy. Any requests cancelled within 48-business hours of the start time of the request will be invoiced for services.*

Clear
Date*

MonthDayYear
Date
Legal

If a field is not applicable, please enter n/a
Case Number*
Caption: X vs. Y*
County*
Court (e.g. General Sessions, Juvenile, Chancery, Circuit, etc.)*
Court Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Case (e.g. criminal, civil, juvenile, etc.)*
Charges*
Courtroom*
Judge*
Plaintiff Attorney*
Defense Attorney*
Check-In Protocol*
Parking Instructions/Availability*
On-Site Contact Person*
On-Site Contact Person Phone*

Area CodePhone Number
On-Site Contact Person Email*
example@example.com
Medical

If a field is not applicable, please enter n/a
DOB/MR#*
Name of Medical Provider Patient is Seeing*

First NameLast Name
What Will Patient Be Seen For?
Room/Suite/Floor*
Will Appt Require a Male or Female Interpreter?
Specialty (e.g. Internal Medicine, OB/GYN, ENT, etc.)*
Brief Description of the Appointment (consult, follow up, surgery, sick visit, pre op, post op, etc.)*
Parking Instructions/Availability*
If multiple entrances to the facility, which is the nearest to your office?*
Mental Health

If a field is not applicable, please enter n/a
Patient MRN/File Number*
Patient DOB*

MonthDayYear
Date
Patient Diagnosis(es)*
Name of the Provider Being Seen*

First NameLast Name
Parking Instructions/Availability*
Should be Empty:

Request for ASL Interpreting Services

Legal

Medical

Mental Health