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LANGUAGE SERVICES

Prisma International Corporation
3324 Peachtree Rd NE, Unit 1219
Atlanta, GA 30326
United States
contact@prisma-international-corporation.com

Explore Services by Prisma International Corporation

Accredited by the Better Business Bureaus Member of American Translators Association Member of International Medical Interpreters Association

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BOOKING INFORMATION (REQUESTOR)
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Requestor Name:

*Requestor Company Name:

*Requestor Phone and Extension:

Requestor Email:

Email where the invoice should be sent upon completion of service

*Requestor Address (Line 1):

Requestor Address (Line 2):

*Requestor City, State:

*Requestor Zip |Postal Code:

*Requestor Country:

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APPOINTMENT & CLAIM INFORMATION
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Service Inquiry | Request:

If you are not booking language services for worker's compensation, SKIP to BENEFICIARY NAME

*Claim Number | Authorization Number

*Beneficiary|Claimant|Patient|LEP Person Name:

*Beneficiary|Claimant|Patient|LEP Person Name:
Phone Number for LEP Client

*Language Requested:

*Appointment Location| Facility Address:
(Street #, Name, City)

*Appointment Facility State|Province:

*Appointment Facility City | Zip Code:

*Main Contact Person at Check In:
First | Last Name | Phone Number (no dashes)

*Service Request Date:

*Appointment | Service (Start) Time:

Service Instructions | Additional Comments:
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Prisma International Corporation
3324 Peachtree Rd NE, Unit 1219
Atlanta, GA 30326
United States
contact@prisma-international-corporation.com

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YOU HAVE A DOCUMENT TO ATTACH?