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Language Access in Health Care Feedback Form
Did the patient have problems obtaining appropriate language services for the encounter?
Please describe the problem by checking all that apply below
Appropriate interpretation not offered (check all that apply)
Check-in/check-out/scheduling (check all that apply)
Appointment/encounter delayed (check all that apply)
If other, please describe:
Your answer
What was the type of interpretation offered (if applicable)?
Was an interpreter ordered through the patient's insurance company?
Visit Information
Date of Visit
MM
/
DD
/
YYYY
Time of appointment/encounter (if applicable)
Time
:
Where did the problem occur?
Name of Clinic/Specialist Practice (if applicable)
Your answer
Clinic/Specialist Practice Phone Number
Your answer
Clinic/Specialist Practice Address/Location
Your answer
Patient Information
What type of insurance does the patient have?
If the patient has Medicaid, what company provides the insurance?
Patient's Preferred Language
If other, please list language below
Your answer
Please provide any positive feedback on the language access services provided for the patient's visit
Your answer
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