MIRF 2.0 - MINT Languages

"*" indicates required fields

General Info

Company Name*

Requester Name*

Requester Phone Number

Ext

Requester Fax Number

Requester Email

Requester Address

Facility Location (Optional)

Today's Date

MM slash DD slash YYYY

Alternative Fax or Email to send the confirmation

Select Type of Service*

Client Info

Client Name

Client Telephone Number

Client's Date of Birth

MM slash DD slash YYYY

Time Zone

Languages*

On-Site Appointment

Address to Send the Interpreter*

Remote Acceptable?

Yes

Time(s) Flexible?

Yes

To reschedule a previous request, enter the new appointment information in the request section and old appointment information to cancel in the cancel section.

Request

Please list all the appointment you would like to request, one appointment per row. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Length in Hours

Appointment Type (ex MD, MRI, Legal)

Cancel

Please list all the appointment you would like to cancel. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Quick Call

To reschedule a previous request, enter the new appointment information in the request section and old appointment information to cancel in the cancel section.

Request

Please list all the appointment you would like to request, one appointment per row. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Flexible? Y/N

Length in Minutes

Appointment Type (ex MD, MRI, Legal)

Phone Number to Call

Cancel

Please list all the appointment you would like to cancel. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Scheduled Video Remote Interpreter (VRI)

I want MINT to provide links

Yes

To reschedule a previous request, enter the new appointment information in the request section and old appointment information to cancel in the cancel section.

Request

Please list all the appointment you would like to request, one appointment per row. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Flexible? Y/N

Length in Hours

Type (MD, MRI, Legal)

Link to Virtual Meeting

Meeting ID & Password

Cancel

Please list all the appointment you would like to cancel. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Scheduled Over The Phone Interpreter (OPI)

To reschedule a previous request, enter the new appointment information in the request section and old appointment information to cancel in the cancel section.

Request

Please list all the appointment you would like to request, one appointment per row. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Flexible? Y/N

Length in Hours

Appointment Type (ex MD, MRI, Legal)

Phone Number To Call

Cancel

Please list all the appointment you would like to cancel. (Click the "+" sign to the right to add rows)

Appointment Date

Appointment Time

Provider Info

Provider's Name

Provider's Email

Provider's Phone

Additional Info

Additional Information

Optional field. Please add additional information such as gender preferences, to request a specific interpreter by name, any flexibility options (like any time Monday morning), etc.

File

Drop files here or

Max. file size: 120 MB.

File Upload (Optional) - attach any additional appointment lists or other relevant information

Billing Information

Please add available information. You can email or fax us additional information later. You need only provide this information once per client. If you have provided it previously leave blank

Work Comp/Auto Claim?

Click the box if this is a Work Comp/ Auto Claim

Insurance Carrier Name

Claim Type

Client's Date of Injury

MM slash DD slash YYYY

Claim Number

Adjuster Name

Adjuster's Phone Numer

Adjuster's Fax Number

Adjuster's Email Address

This is an AUTO claim

No Claim Information?

I do not have claim information yet

Attorney on Record?

Click the box if there is an attorney on record

Law Office & Attorney Name

Attorney Phone Number

Attorney Fax Number

Attorney Email Address

No Attorney Information?

I do not have attorney information yet

QRC?

Click the box if this case has a QRC or Case Manager

QRC Name

QRC Cell Number

QRC Fax Number

QRC Email Address

No Attorney Information?

I do not have QRC information yet

Add PMAP?

Click the box to add PMAP, other insurance information, or invoicing instructions

Insurance Carrier Name*

Patient Member ID (PMI)*

Date of Birth

MM slash DD slash YYYY

Any Additional Insurance or Invoicing Information or Instructions

Optional field. Please add additional insurance or other information you would like us to know

MINTNow!

Do you have a MINTNow! account?*

Name of Person to Contact*

Title

PIN #

Contact Email

Contact Phone Number

Ext

Questions or Customer Service Request

Please explain your needs and other information about setting up your account

Document Translation

I am...

Files

Drop files here or

Max. file size: 120 MB.

Please upload all files or Zipped folder

We are Requesting

Source Language*

Language your documents are in. For example, English

Target Languages*

All language(s) you would like your document(s) to be translated into

Project Due Date

MM slash DD slash YYYY

RUSH?

Yes

(Rush fee applies)

Please contact me to discuss project

Yes

Special Instructions

Additional Language Services

Please provide as much information about the service you would like to request as you can and we will contact you to review the details of your request.

I am...

Files

Drop files here or

Max. file size: 120 MB.

Please upload all files or Zipped folder

I am requesting...

Describe project here in a few words. For example, Audio Transcription OR Audio Spot, Multimedia (captioning, audio translation ), Training Material (Tutorials, templates, Manuals), etc.

Project Due Date

MM slash DD slash YYYY

RUSH?

Yes

(Rush fee applies)

Please contact me to discuss project

Yes

Source Language*

For example, English

Target Language(s)*

All language(s) you would like your file(s) to be translated into

Special Instructions

Billing Information

Invoice sent to:

Title

Contact Email

Contact Phone Number

Ext

Fax

Additional Invoicing Information or payment Instructions

Optional field. Please add any information you would like us to know

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