FM.I9.1 5/21 Patient Name: Address: DOB:
INTERPRETER SERVICE RECORD
Age:
Male
Female
NHI:
1. NAME OF PERSON ARRANGING INTERPRETER, PROVIDER AND ASSIGNMENT DETAILS NB: Please complete patient details above or attach patient label Name (print):
Contact Phone Number:
Ward/Dept:
Date interpreter required:
Ezispeak BOP
Authorised Interpreter List
Estimated cost = $1.70 per minute or $2.70 after hours
The section below is to be completed on the day of the assignment
Click to EMAIL your Cost Centre Manager Manager byby adding to cc Click to EMAIL your Cost Centre adding tofield CC field
2. THIS SECTION MUST BE COMPLETED FOR ALL BOP AUTHORISED INTERPRETER LIST USE Payment is for BOPDHB Authorised Interpreter List members is a flat rate of $50 per hour or part thereof and does not include associated costs such as travel time. This Interpreter Service Record is not a tax invoice.
I certify that the hours of assignment noted above worked are true and correct Time start:
Time finish:
Interpreter’s name:
Interpreter’s signature:
BODHB Staff member:
Yes
No
Service provided during work hours
Yes
No
Or out of work hours
Yes
No
Remember Staff Members providing interpreter services during work hours cannot claim payment. Print and ask Interpreter to sign, give one copy to interpreter and one copy to your cost centre Manager
NB: The section BELOW must be completed and forwarded to Accounts Payable for all interpreter use! 3. AUTHORISATION FOR PAYMENT BY COST CENTRE MANAGER OR AUTHORISED DELEGATE Print name: Purchase order number:
Signature: Amount approved:
Signed master to be sent to Accounts Payable for payment, copy to be filed in patient’s health record and a copy given to BOPDHB Authorised List Interpreter member providing the service.
EMAIL to BOPDHB ACCOUNTS PAYABLE
CLEAR FORM