MIS Form (Subcontractors/Bilingual Interpreters)

MIS FORM

Independent Contractor/Bilingual Freelance Interpreter
Your Name: (Independent Contractor/Bilingual Freelancer)

First NameLast Name
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Language:
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
MRN:
Optional
Patient Phone Number:
Please enter a valid phone number of the patient.Format: (000) 000-0000.
Date of Appointment:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Appointment:

Hour Minutes

AM/PM Option
Time In:

Hour Minutes

AM/PM Option
Time Out:

Hour Minutes

AM/PM Option
Provider:
Agency/Location:
Notes:
Please enter next app. date/time and any other comments regarding the assignment.
Authorized Signature:
DATE:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Service
Duration Total in Minutes: (Optional)
This form belongs to the service provider and not MIS. This is a Purchase Order. The services provider is a Subcontractor/Independent Contractor or Bilingual Freelancer.
Should be Empty:

MIS FORM