Aging and Long-Term Support Administration

Apple Health Providers (Medicaid) Sign Language Interpreter Request Form (old)

6/21/2024 3:06:35 PM
Required Fields are in bold
You will receive a service request number after submitting this form. Keep this number for your records. It is essential for cancelling Interpreters when appointments are cancelled.

Purchaser Information

Purchaser information refers to you, the individual making this request. The Contractor will follow up with you as needed.
First Name   Last Name  

Billing information: This form is intended for providers who wish to use Health Care Authority's Sign Lanaguage Services. Payment for authorized clients will be covered through Medicaid. It is the provider's responsibility to make sure the patient has active Apple Health coverage. If the patient's Apple Health is inactive, Health Care Authority will not cover this appointment. The Contrctor will then bill you (The Provider) for Sign Language Interpreter Services. Under the ADA, medical providers are legally responsbile to provide reasonable accommodations.

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Appointment Information

Appointment Type
Appointment Date
Appointment Time Start Time
End Time
Is this meeting being recorded?
Appointment Setting
Appointment Note Please describe the appointment: For example: A Deaf child with hearing parents are meeting with primary care physician for a general checkup.  The patient is a DeafBlind adult coming in for follow up appointment. 

Appointment Location

Provide a detailed description of the service location. This helps the interpreter(s) find the location successfully. Due to COVID, many appointments are now taking place through a virtual platform. Please add your physical location and the meeting’s Virtual information. If there is no virtual information, the Interpreter will show up at the physical location, and you will be responsible for travel and mileage.
Contact   Phone  (If other than requestor)
Email (If other than requestor)   Text
Name of Medical Building (if applicable)
Room Number
City State
Zip Code
Virtual Meeting
Virtual Meeting/Platform
Mixed Group
Direction & Parking Note

Patient Information

Provide information about the client/consumers being serviced. This includes special requirements and preferences.
Patient's First Name Patient's Last Name
Deaf Participant/Party
(other than patient name)
Patient's Provider One #
Hearing Identity
Date of Birth (mm/dd/yyyy)
Specific Interpreter Requested

You must select a contractor from the list below: Please note, not all contractors are statewide. If you need information about each Contractor, please go to ODHH's website.


If you have any comments you want to relay to our contractors and/or interpreters, please enter them below.

Once you submit your request, you will receive an email copy of the request with the service request number. Please keep this for your records.