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Section 1 of 2
Language Access in Health Care Feedback Form
Did the patient have problems obtaining appropriate language services for the encounter?
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Yes
No
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add "Other"
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Please describe the problem by checking all that apply below
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Appropriate interpretation not offered (check all that apply)
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Office refused to provide or schedule any language services
Office wanted a family member or friend to act as interpreter
An employee who was not a professional interpreter provided interpretation
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add "Other"
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Check-in/check-out/scheduling (check all that apply)
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Interpretation not provided for check-in/check-out
Lack of appropriate language services made scheduling or telephone-based services difficult
Standard forms were not available in patient's preferred language (e.g. HIPAA notice)
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Appointment/encounter delayed (check all that apply)
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interpreter was ordered but did not arrive
Patient's appointment was rescheduled because an interpreter or bilingual staff member was not available
Patient's appointment was late because an interpreter or bilingual staff member was not available
Interpretation was available for only part of the visit
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If other, please describe:
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What was the type of interpretation offered (if applicable)?
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Telephonic
In-Person Interpreter
Medical Staff (Physician, Nurse, Etc.)
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Was an interpreter ordered through the patient's insurance company?
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Yes
No
Unknown
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Visit Information
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Date of Visit
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Time of appointment/encounter (if applicable)
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Where did the problem occur?
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Name of Clinic/Specialist Practice/ Mental Health Provider (if applicable)
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Clinic/Specialist Practice/ Mental Health Provider Phone Number
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Clinic/Specialist Practice Address/ Mental Health Provider Location
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Patient Information
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What type of insurance does the patient have?
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Medicaid
Medicare
Marketplace/ "Obamacare" Insurance
Employer-Insurance
Uninsured
Unknown
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Does the patient have CBH funded MH care?
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Yes
No
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add "Other"
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If the patient has Medicaid, what company provides the insurance?
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Keystone First
Aetna Better Health
Health Partners
United Healthcare Community Plan
Other…
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Patient's Preferred Language
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1.
Amharic
2.
Arabic
3.
Burmese
4.
Cambodian
5.
Chin (Hakha, Tedim, Falam)
6.
Chinese
7.
Indonesian
8.
Karen
9.
Kinyarwanda
10.
Nepali
11.
Sudanese Arabic
12.
Swahili
13.
Thai
14.
Vietnamese
15.
OTHER
16.
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If other, please list language below
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Please provide any positive feedback on the language access services provided for the patient's visit
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Section 2 of 2
Contact Info
Name of person completing this form
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