Referrals - iLingo

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Referrals

To make a referral, please select the service and complete the form.

A representative will contact you within 24 hours.

1Request Services

2Submitter Information

3Payor/Adjuster Info Billing Information

4Nurse Case Manager Information

5Injured Worker Information

Select a Service*
- On-site Interpretation
- Telephonic Interpretation
- Transportation
- Document Translation
- Video Remote Interpreting
Transportation
Transportation Type*
Appointment Type
Pick Up From Info
Pick up from home*
Facility Name
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Destination Info
Facility Name
Type
Facility Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Scheduling Info
Date of Service*
MM slash DD slash YYYY
Pickup Time

: Hours

Minutes

AM/PM
Appointment Time*

: Hours

Minutes

AM/PM
Round Trip?
Wait Time Authorized?
Will Call For Return
Recurring
How Often?
Special Instructions
On Site Interpretation
Language
Appointment Type
Address Info
Facility Name
Facility Type
Facility Phone
Address
Street Address City State / Province / Region ZIP / Postal Code
Scheduling Info
Date of Service*
MM slash DD slash YYYY
Appointment Time*

: Hours

Minutes

AM/PM
Arrival Time*

: Hours

Minutes

AM/PM
Special Instructions
Transcription and Document Translation
Document Needed By*
MM slash DD slash YYYY
Language*
Email for Sending*
Upload File*
Max. file size: 50 MB.
Special Instructions
Telephonic Interpretation
Language
Call Type
Scheduling Info
Date of Service*
MM slash DD slash YYYY
Appointment TIme

: Hours

Minutes

AM/PM
Special Instructions
Video Remote Interpreting
Language
Call Type
Scheduling Info
Date of Service*
MM slash DD slash YYYY
Appointment TIme

: Hours

Minutes

AM/PM
Special Instructions