In-person Interpreter Services Request Form

In-person interpreter availability is limited, so please let us know at least five business days before the appointment to ensure the interpreter can be scheduled. Cancellations require at least 48-hour notice to HPSM before the appointment request date. Please note that your request is not considered fulfilled until you receive a confirmation email from HPSM verifying that the interpreter has been scheduled. If you have questions about in-person interpreters, email

Patient's Information

Appointment information

(i.e. list the treatments, types of procedures and/or specific health concerns to be addressed during this visit.)

Provider's information