AETNA Language Services Request Form

To Schedule Interpretation Services Please Fill Out The Following Information.

(Propio fulfillment specialist will provide interpreter with your name & number in case a call is required)

Name of Requester *

Name of Requester is required.

Requester's Phone Number *

Requester's Phone Number is required.

Requester's Email *

Requester's Email is required.

Secondary Email

Name of Business Area *

Name of Business Area is required.

Cost Center Number or PO Number *

Cost Center Number is required.

Name of Person Requesting Service *

Name of Person Requesting Service is required.

Address of Appointment *

Address of Appointment is required.

Type of Appointment *

Please select Type of Appointment.

Delivery of Service *

Please select Delivery of Service.

Appointment Date *

Please enter Appointment Date.

Appointment Time *

Appointment Time is required.

Time Zone *

Time Zone is required.

Appointment Duration *

Appointment Duration is required.

LEP Member's First Name *

LEP Member's First Name is required.

LEP Member's Last Name *

LEP Member's Last Name is required.

LEP Member's D.O.B. *

LEP Member's D.O.B. is required.

Member Data on file with Propio (if unsure, please provide all the data requested below)

Member's Language *

Member's Language is required.

Interpreter Gender Preference

Virtual Interpreting – Client Platform Link

Assignment Details

Documents/Presentation Material Interpreter will need prior to assignment

Upload file(s)...