Interpreter form - ESPAÑOL Yo, _________________________...

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CONSENT FORM  FOR USE OF  LANGUAGE INTERPRETER I, __________________ hereby give my permission to _______________________________, to use a  language interpreter for the purposes of communicating medical information.   I understand that the  interpreter will have access to my medical information, only through the interpretation of this information.  I understand that the interpreter will NOT have access to my written medical records.   Language Interpretation required:  __________________________________________ Including Sign-Language, Spanish, etc Permission Granted by: _______________________________________________________ (Signature of Patient, or Guardian)  Date of Signature:  ________________________________________________ Interpreter:  ________________________________________________ Date of Birth: __________________ SS#_________________________ FORMA DE CONSENTIMIENTO PARA USAR A UN INTERPRETER
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Unformatted text preview: ESPAÑOL Yo, _________________________ doy mi consentimiento a ____________________________ para obtener un interprete para la intencion de communicando information medico. Yo entiende y estoy en acuerdo que el interprete tience acceso a mi informacion medica, solamente para interpretar esta informacion. Yo entiende que el interprete NO tiene acceso a mi datos medicos. Lenguage de Interpretacion requerido: ___________________________________ Firma de Consentimiento: __________________________________________ (Firma del paciente o guardián) Fecha de firma: ________________________________________________ Firma de Interprete: ________________________________________________ Fecha de Nacimiento: _____________________ SS#__________________ Dr. Signature: ________________________________________________...
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This note was uploaded on 10/27/2011 for the course PHYCOLOGY 101 taught by Professor Eins'tein during the Spring '11 term at Albany Medical College.

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Interpreter form - ESPAÑOL Yo, _________________________...

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