Encore Transportation & Language Services HomeAbout UsTransportationLanguageRequest ServiceContact Us Request for Services 1 Step 1 Request for ServicesPlease fill out the following information on the request form below. (check all that apply)InterpretationTransportationInterpretation & Transportation Interpretation Type:Select An OptionInterpretationTranslationTelephonic Language:Select An OptionEnglishSpanishBosnianVietnamesePortugueseOther Transportation Type:Select An OptionAmbulatoryWheelchairStretcherNon-Emergency Ambulance Requestor Name: Your Position:Select An OptionCase ManagerAdjusterOther Phone: Fax: Email:email Injured Worker Information Injured Worker Name Address Line 1: Apt # / Suite #: City: State: Zip: Primary Phone: Secondary Phone: SSN/Claim Number: Employer of Injury: Date of Injury:date_range Type of Injury: Appointment Information Appointment Date:date_range Appointment Time: Appointment Location: Address Line 1: Apt # / Suite #: City: State: Zip: Phone: Ext: Billing Information Insurance Carrier: Billing Address: Apt # / Suite #: City: State: Zip: Claim #: Authorizing Adjuster: Phone: Ext: Special Instructions:0 / 2000 Submit Request keyboard_arrow_leftPrevious Nextkeyboard_arrow_right
