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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 *
Time of appointment/encounter (if applicable)
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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