Interpreter Request Form

Is this an initial appointment/assessment? *

Yes No

**Please note, if this request is not an initial appointment, call (800) 224-1991, five minutes prior to the appointment, during Cenpatico’s normal operating hours. An interpreter will be secured by phone at that time.**

Appointment Type

Medication Management Psychological Therapy Psychological Testing Other – Please Specify

Please specify appointment type *

Requestor's First Name *

Requestor's Last Name *

Requestor’s Email Address *

Facility/ Provider Name *

Tax ID of Rendering Provider *

NPI of Rendering Provider *

Phone Number *

Fax Number

Member's First Name *

Member's Last Name *

Member’s Medicaid ID *

Member's Date of Birth *

Date of Appointment *

Product Type

Duals Medicaid

Time of Appointment *

Expected Duration * (in minutes)

Address of Appointment *

City *

ZIP Code *

State *

Place of Service Code (Please select from the following locations) *

School (03) Office (11) Home (12) CMHC (53) Other (99)

Please specify place of service *