Billing is based on 1-hour minimum. Be accurate when indicating START and END times. Services are provided on request, subject to the availability of staff and independent contractors. This form must be filled out LEGIBLY and COMPLETELY. Illegible and incomplete forms will be returned by email or fax.

Cancellations must be in writing and received a minimum of 48-business hours in advance.

Start time of appointment. One hour minimum.
End time of appointment

REQUESTOR INFORMATION

TYPE OF SERVICES REQUESTED (Check all that apply)
* means 2 interpreters
Real-Time Captioning "No Edits" Transcription
Real-Time Captioning w/ Professional Transcription
Video/Webinar/Public Space Recording
Primary Spoken Language
More than one primary language
Name of Deaf Consumer
Other Consumer's Name (optional)
Appointment Information / Location Name

PROVIDER INFORMATION

Provider's Name
Site Contact Person

BILLING INFORMATION

Billing Address

REQUIRED SIGNATURE

By signing this request, you are agreeing to the terms and conditions in the Service Agreement and to pay for services requested/provided. By submitting this and future requests by electronic means, I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. Access Communication Today! does not bill third parties or the Deaf or hard of hearing consumer
Clear Signature