Hello. Please sign in!

United States of America v. Associated Foot & Ankle Centers of Northern Virginia - Settlement Agreement

This document, portion of document or clip from legal proceedings may not represent all of the facts, documents, opinions, judgments or other information that is pertinent to this case. The entire case, including all court records, expert reports, etc. should be reviewed together and a qualified attorney consulted before any interpretation is made about how to apply this information to any specific circumstances.

Exhibit A




Name of Person with Disability
Patient's Name (if not person with disability)
Nature of Disability: Relationship to Patient:



__ Hard of Hearing

__ Family Member
__ Speech Disability

__Friend / Companion

__ Other: ______________ __ Other: ______________

Do you want a professional sign language or oral interpreter for your visit?

__No. I do not use sign language and do not use interpreters to lip read.
__No. I prefer to have family members/ friends help with communication.
__No. I do not feel an interpreter is necessary or do not want one for this visit.
__Yes. Choose one (free of charge):

__American Sign Language (ASL) interpreter
__Pidgin Signed English (PSE) interpreter
__Signed English interpreter
__Oral interpreter
__Other. Explain: _____________________________

Which of these would be helpful for you for effective communication? (free of charge)

__TTY/TDD (text telephone)

__Assistive listening device (sound amplifier)
__Qualified note-takers

__Writing back and forth
__CART: Computer-assisted Real Time Transcription Service
__Other. Explain: _________________________________________

We ask this information so we can communicate with you effectively. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask a member of our office staff.

Any questions? Please call our office, ______________(voice), ______________ (TTY), or visit us during normal business hours.


*You must sign in to view [MORE INFO...]