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 interpreters@hpsm.org.

Patient's Information

Patient's name:

Date of birth:

HPSM Member ID #:

HPSM program enrollment:

Appointment information

Type of interpreter:

Language:

Type of appointment:

Appointment date:

Start time:

Appointment duration:

Please describe the purpose of the visit:

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

Provider's information

Name of provider:

Provider's email:

Name of primary contact:

Contact's phone:

Address of clinic or practice:

Name of requester:

Requester's phone:

New code

Please type the code above

HPSM's Updated Privacy Practices

Monkeypox information

Power Outages

In-person Interpreter Services Request Form

Patient's Information

Appointment information

Provider's information