Waiver of Interpreter Services

PROVIDED BY HARTFORD HEALTHCARE

It is your choice whether you use the interpreter service provided by Hartford Healthcare. By signing below, you are indicating that Hartford HealthCare has offered to provide you [or your loved one] with an interpreter, free of charge, and that you have declined the organization’s offer.

Please check all that apply below: 

• I waive my right to request that Hartford HealthCare provide me with an interpreter for this specific visit.
• I have been informed of the range of auxiliary aids and services that are available to me [or my loved one] free of charge. 
• I have been informed that Hartford HealthCare does not require a patient or companion to bring someone to interpret for him or her.
• I request that [insert name of individual] interpret, translate or facilitate communications between the HHC staff and the patient. 

***If at any point during your visit, you wish to change any of the answers to the questions on this form or revoke your waiver, please notify your nurse.