Interpreter Request Step 1 of 4 25% For Rite Care, Exchange (Commercial), Rhody Health Partners and Rhode Health Partners ACA only. Language Services requests require 72 Business hours notice prior to the appointment. American Sign Language (ASL) requests require 14 business days notice prior to appointment.Request Type*Request Type *New AppointmentCancelling AppointmentTime ChangeRequestor InformationProvider's Full Name* Phone*Phone Extension Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Individual Completing Form* First Last Phone*Phone Extension Email Address for Receipt* Return Fax NumberType of Appointment*Type of Appointment *MedicalBehavioral Health Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Member's Plan Name* Member's Name* First Last Error Message Member's Phone #*NOTE: Multiple dates of service can be submitted on this form as long as they are within 7 days from the first date of service.HiddenDate and Time to show when New or Cancel appointment is selectedDate of Visit/Service* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Date of Visit/Service MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Date of Visit/Service MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Date of Visit/Service MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM HiddenDate and Time to show when Time change appointment is selectedFirst set of Date and Time to changeCurrent Date of Visit/Service* MM slash DD slash YYYY Current Time* : Hours Minutes AM PM AM/PM To Date of Visit/Service* MM slash DD slash YYYY To Time* : Hours Minutes AM PM AM/PM Second set of Date and Time to changeCurrent Date of Visit/Service MM slash DD slash YYYY Current Time : Hours Minutes AM PM AM/PM To Date of Visit/Service MM slash DD slash YYYY To Time : Hours Minutes AM PM AM/PM Third set of Date and Time to changeCurrent Date of Visit/Service MM slash DD slash YYYY Current Time : Hours Minutes AM PM AM/PM To Date of Visit/Service MM slash DD slash YYYY To Time : Hours Minutes AM PM AM/PM Fourth set of Date and Time to changeCurrent Date of Visit/Service MM slash DD slash YYYY Current Time : Hours Minutes AM PM AM/PM To Date of Visit/Service MM slash DD slash YYYY To Time : Hours Minutes AM PM AM/PM Length of Visit/Service*30 mins1 hour1 hour 30 mins2 hours2 hours 30 mins3 hours3 hours 30 mins4 hours Appointment LocationAddress*Complete address where interpreter services are to be provided: office number, name of clinic, dept name and floor # or other Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Phone Extension Language*Language *LanguageSign LanguageLanguage Selection*SpanishPortugueseAfrican CreoleAmharicArabicArmenianBassaBembeBhunan (Nepaliese}BurundiCameroon-MinaCape Verdian CreoleChineseChinese - CantoneseChinese - MandarinChinese - ToisanDanFarsi (Persian)FrenchFrench CreoleFulaniGbandeGioGreboGujaratiHaitian CreoleHindiHindi-PunjabiHindi-UrduHinduHmongJapaneseKabaKepelleKhmer (Cambodian)KikongoKinyarwandaKirundiKissiKrahnKruKunamaKurdishLaoLaotianLebaneseLegaLingalaLormaMalinkeMandingoMandinkaManoMendiNepaliOlouf-SenegalPersianPolishQuicheRussianSangoSwahiliTagalogThaiTigrinyaTshilubaTwiUrduViaVietnameseWolofYorubaOtherLanguage Other* Preference*Preference *MaleFemaleNo PreferenceNo Preference If preference is not available it is OK to send non-preferred gender.Special Instructionsapartment #, floor, parking, etcCAPTCHA