Free 46812.pdf - Indiana

INTERPRETER SERVICE PROGRAM
State Form 46812 (R / 6-96) / DHHS 0001

Service authorization number

Mail to: Deaf and Hard of Hearing Services Family and Social Services Administration Division of Disability, Aging, and Rehabilitative Services P.O. Box 7083 Indianapolis, IN 46207-7083

Name of vendor

Name of state agency

Name of requestor

Telephone number

Requestor address (number and street, city, state, ZIP code)

Name of consumer(s)

Situation

Service date

Date requested Actual service time PM to AM PM AM PM to

Date confirmed Total service time AM PM

Requested service time AM

Site of service address (number and street, city, state, ZIP code)

Travel from:

Travel to:

Total miles (round trip)

Name of Interpreter(s)

Signature of authorized vendor representative

Title

Date (month, day, year)

Administrative instructions and / or explanations

DISTRIBUTION: White - DHHS; Canary - Contractor