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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)
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
Check-in/check-out/scheduling (check all that apply)
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)
Appointment/encounter delayed (check all that apply)
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
If other, please describe:
What was the type of interpretation offered (if applicable)?
Medical Staff (Physician, Nurse, Etc.)
Was an interpreter ordered through the patient's insurance company?
Date of Visit
Time of appointment/encounter (if applicable)
Where did the problem occur?
Name of Clinic/Specialist Practice (if applicable)
Clinic/Specialist Practice Phone Number
Clinic/Specialist Practice Address/Location
What type of insurance does the patient have?
Marketplace/ "Obamacare" Insurance
If the patient has Medicaid, what company provides the insurance?
Aetna Better Health
United Healthcare Community Plan
Patient's Preferred Language
Chin (Hakha, Tedim, Falam)
If other, please list language below
Please provide any positive feedback on the language access services provided for the patient's visit
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