State and Federal Legislation

State and federal regulations, along with industry standards, mandate equitable access to services regardless of the language(s) used. Several state and federal regulations have implications for audiologists, speech-language pathologists (SLPs), and assistants collaborating with interpreters, transliterators, and translators. These legal requirements aim to ensure that all patients receive high-quality, accessible health care services and promote better health outcomes. For more information, visit ASHA’s resource on understanding language access requirements for audiologists and SLPs.

Rights to language access may come from multiple pieces of legislation. As of 2019, every state and the District of Columbia have at least three laws addressing language access (Youdelman, 2019). Differences in state regulations may be reflected in several requirements. See the National Health Law Program’s Summary of State Law Requirements Addressing Language Needs in Health Care.

Americans With Disabilities Act of 1990

The Americans with Disabilities Act of 1990 (ADA) prohibits discrimination and ensures equal opportunity for persons with disabilities in the areas of employment, state and local government services, public accommodations, commercial facilities, and transportation. Congress has mandated the need for auxiliary aids and services—such as interpreters, transliterators, and translators—to ensure equal opportunity for individuals with disabilities (Americans with Disabilities Act of 1990). To confirm compliance, consult ADA’s Checklist for General Effective Communication.

Equal Educational Opportunities Act of 1974

The Equal Educational Opportunities Act of 1974 states, “All children enrolled in public schools are entitled to equal educational opportunity without regard to race, color, sex, or national origin.” No state can deny students the right to equal education by “failure by an educational agency to take ‘appropriate action’ to overcome language barriers that impede equal participation by its students in its instructional programs” (Equal Educational Opportunities Act of 1974).

Individuals With Disabilities Education Act

For school-age children, the Individuals with Disabilities Education Act (IDEA) was enacted to ensure that all children with disabilities (ages 0–21 years) have a free and appropriate public education available that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living.

Part B

IDEA states that, in the development, review, and revision of an individualized education program (IEP), the team must consider several factors with regard to interpreters:

(iv) consider the communication needs of the child, and in the case of a child who is deaf or hard of hearing, consider the child’s language and communication needs, opportunities for direct communication with peers and professional personnel in the child’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the child’s language and communication mode; and (v) consider whether the child needs assistive technology devices and services. [IDEA § 1414(d)(3)(B)]

Parents and IEP teams assign or hire an interpreter based on the child’s mode of communication. With respect to children who are d/Deaf or hard of hearing (D/HOH), this includes oral transliteration; cued language transliteration; sign language interpreting, and interpreting, and transcription services, such as Communication Access Realtime Translation (CART), C-Print, and TypeWell [IDEA, 34 C.F.R. § 300.34(c)(4)].

Services for multilingual learners must take the language(s) of the home into consideration for both assessment and intervention. For children who receive services with an IEP under Part B (ages 3–21 years):

When evaluating English language learner (ELL) students, it is important for speech-language pathologists (SLPs) to carefully review the child’s language history to determine the language of assessment. If it is determined that the child should be evaluated in a language other than English, the SLP must use all available resources, including interpreters, when necessary, to appropriately evaluate the child. (ASHA, n.d.-a, para. 4)

See ASHA’s resource on IDEA Part B: Culturally and Linguistically Diverse Students and Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Part C

For children who receive services with an individualized family service plan under Part C (from birth to 2 years of age):

Sections 303.321(a)(5) and 303.321(a)(6) state that all evaluations and assessments of a child must be conducted in the native language of the child, in accordance with the definition of native language in §303.25, unless clearly not feasible to do so. While the phrase “unless clearly not feasible to do so” was added to acknowledge that there may be instances where conducting an assessment in the child’s native language is not possible, the U.S. Department of Education, in the discussion section of the final regulations, clarifies that best efforts should be put forth to locate an on-site or telephonic interpreter when needed. (ASHA, n.d.-b, para. 4)

“Native language,” as defined in Section 303.25(a)(1) of IDEA, means “the language normally used by that individual, or in the case of a child, the language normally used by the parents of the child.” See ASHA’s resource on IDEA Part C: Cultural and Linguistic Diversity.

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides national standards to protect the privacy of protected health information. Some regulations include provisions related to service providers working with language assistance providers.

HIPAA allows covered health care providers to share a patient’s health information with an interpreter without the patient’s written authorization under the following circumstances:

• A health care provider may share information with an interpreter (e.g., a bilingual employee, a contract interpreter on staff, or a volunteer) who works for the provider.
• A health care provider may share information with an interpreter who is acting on its behalf (but who is not a member of the provider’s workforce) if the health care provider has a written contract or other agreement with the interpreter that meets HIPAA’s business associate contract requirements.
• A health care provider may share information with an interpreter who is the patient’s family member, friend, or other person that the patient identifies as their interpreter, provided that (a) the patient agrees, or does not object, or (b) the health care provider determines, using their professional judgment, that the patient does not object.

Title VI of the Civil Rights Act of 1964

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on national origin, which the Supreme Court, the Department of Health and Human Services, and other federal agencies have interpreted to include language. Any organization receiving federal funding—such as Medicaid and Medicare—must still provide meaningful language access to individuals with limited English proficiency (LEP).

Section 1557 of the Affordable Care Act

Section 1557 of the Affordable Care Act (2024) prohibits discrimination in covered health entities or activities. “Covered health entities” (the term used in this legislation) may include the following:

• hospitals
• health clinics
• health insurance issuers
• state Medicaid agencies
• community health centers
• physicians’ practices
• home health care agencies

Health entities must also take reasonable steps to provide meaningful access to people who use languages besides spoken English. Covered health programs or activities are also required to post taglines in at least the top 15 languages in their state. Taglines are brief messages in documents and websites that explain how a person can obtain a translation of the document or request an interpreter to explain the document for them in their heritage language(s).

Section 504 of the Rehabilitation Act of 1973

Section 504 of the Rehabilitation Act of 1973 protects people with disabilities, including people who are D/HOH, from discrimination in any program or activity receiving federal funding. Section 504 ensures that people with disabilities have equal opportunity, with reasonable accommodations, to access and participate in education, employment, and health care. Section 504 protections include effective communications (e.g., on-site or remote interpretation services, screen reader software), telecommunications, and signage (45 C.F.R. § 84).

On March 1, 2025, the Trump administration issued an executive order “Designating English as the Official Language of The United States.” Although this executive order indicates a shift in stance and revokes the Clinton-era Executive Order 13166 [PDF], existing language protections under federal law still stand. This executive order does not undo existing language access obligations tied to federal funding (González-Cestari, 2025). The executive order states that “nothing in this order, however, requires or directs any change in the services provided by any agency” [Section 3(b).

Health Care and Organization Standards

The Joint Commission accredits and certifies health care organizations and programs in the United States. Patient-centered communication standards for hospitals are published in the Comprehensive Accreditation Manual for Hospitals (The Joint Commission, n.d.). The standards address issues such as qualifications for language interpreters and translators, identifying and addressing patient communication needs, collecting patient race and ethnicity data, patient access to a support individual, and nondiscrimination in care.

National Culturally and Linguistically Appropriate Services Standards

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (Office of Minority Health, n.d.) aim to advance equitable and quality health care and help eliminate health care disparities by providing a model for professionals and health care organizations to implement culturally and linguistically appropriate services (CLAS). Although these guidelines are not federal law, they are recommended by the U.S. Department of Health and Human Services Office of Minority Health. The CLAS standards for communication and language assistance are as follows (Office of Minority Health, n.d.):

5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. (Communication and Language Assistance)

Ethics

Legal and ethical considerations are foundational to appropriate services. There may be times when services meet legal (local, state, federal) regulations/requirements but do not meet the fundamentals of ethical conduct. Codes of ethics or professional conduct are principles designed to help professionals conduct business honestly and with integrity. It is critical that clinicians have a working knowledge of both legal and professional ethics standards (i.e., practicing antidiscrimination in the provision of services, ensuring patient privacy)—as they pertain to working with interpreters, transliterators, and translators—to ensure appropriate clinical interactions.

The ASHA Code of Ethics (ASHA, 2023b) provides the fundamentals of ethical professional conduct. Principles of Ethics and Rules of Ethics are specific statements of minimally acceptable—as well as unacceptable—professional conduct and apply to all individuals who are ASHA members and/or certificate holders or who are applicants for certification.

The clinician is responsible for understanding cultural and linguistic variables that may impact service delivery. For further information, please see ASHA’s Practice Portal page on Cultural Responsiveness.

Although providing cross-linguistic services may require the assistance of trained interpreters or multilingual professionals, it is the responsibility of the clinician to understand the influence of cultural and linguistic variables on communication, such as second-language acquisition, dialectal differences, interference/transfer, and translanguaging. Ultimately, the clinician is responsible for the appropriate diagnosis and treatment/management of communication disorders within and across world languages and dialects as well as swallowing and balance disorders.

Periodically, the Board of Ethics develops Issues in Ethics statements when further clarification and guidance are needed to assist in ethical service delivery. The Issues in Ethics statement, Cultural and Linguistic Competence (ASHA, 2017), specifically addresses working with interpreters for the provision of services. ASHA’s Prohibitions Against Discrimination Under ASHA Code of Ethics and Enforcement by the Board of Ethics emphasizes the importance of ethical service delivery in communication sciences and disorders or in the professions of audiology and speech-language pathology.

Language Access Planning

The responsibility of language access planning varies based on a clinician’s setting. For school settings, the school district provides language access to students and their families regardless of whether they are in general or special education. If an SLP is a case manager, then they have a responsibility to follow the school district’s language access plan. Below are the considerations for language access planning for health care providers and agencies, including private practice settings, based on the provided resources:

1. Legal and regulatory requirements: Multiple federal laws mandate nondiscrimination based on race, color, national origin, sex, age, or disability. Legal and regulatory requirements include, but are not limited to, Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, and Section 1557 of the Affordable Care Act. In addition to federal laws, state laws provide an additional source of protection. As of 2019, every state and the District of Columbia address language access with multiple laws (Youdelman, 2019). For more information, see the State and Federal Legislation section of this document.
2. Assessment of language needs: Providers and organizations can conduct a needs assessment to identify the languages that may be necessary for language assistance services. Examples of activities and data collection tools include the following:
   • Review demographic data from the S. Census Bureau or local health departments to determine the language needs of the community, including the most common languages.
   • Include questions about languages used, communication needs, and preferences on patient intake forms.
   • Incorporate fields into electronic health record or electronic medical record systems to capture patients’ language preferences and communication needs, for ongoing data collection and accessibility.
   • Use language identification tools, such as “I Speak” cards [PDF], to help people identify their language(s).

Visit the U.S. Department of Health and Human Services’ Limited English Proficiency (LEP) Resources for Effective Communication and Limited English Proficiency (LEP) web pages for more information.

3. Provision of language assistance services: Key considerations that guide planning for the provision of language assistance services include the following:
   • Informing people about free language assistance services through signage, brochures, and verbal announcements in multiple languages.
   • Offering qualified and trained interpreters, translators, and transliterators, for in-person and remote encounters based on patient needs.
   • Providing language assistance in a timely manner to avoid delays in care by having interpreters and translated materials that are readily accessible.
   • Ensuring availability of accurate and culturally appropriate written translations of vital documents, such as consent forms, discharge instructions, and patient education materials.

For more information, see the U.S. Department of Health and Human Services’ 2024 U.S. Department of HHS Language Access Plan [PDF].

4. Development of a language access plan: Common sections of a comprehensive language access plan include needs assessment, language services, notices, training, and evaluation. Audiologists, SLPs, and assistants can have the following roles in language access planning:
   • Reviewing (or creating) the comprehensive language access plan that outlines policies, procedures, and resources for providing language assistance at the work setting.
   • Becoming familiar with (or outlining) specific action steps and staff responsible for language access compliance, implementation, and quality assurance.
   • Providing critical input, feedback, and/or support toward the development and implementation of language access plans.

Read more in Centers for Medicare & Medicaid Services’ Guide to Developing a Language Access Plan [PDF].

5. Training and education: All staff and contractors receive training on how to implement the language access plan. Sample areas for education, information, and training to support language access are as follows:
   • legal requirements for language access and impact on patient satisfaction and outcomes
   • language assistance resources, protocols, and organizational points of contact
   • benefits and strategies for promoting communication access for patients, health professionals, and health care systems
   • identification and documentation of language and communication needs of patients
   • language assistance provider roles and how to effectively collaborate with them in person and remotely
   • cultural responsiveness—recognizing and responding to the influence of language and culture on service delivery and outcomes
   • regular training and/or updates on best practices as well as language access policy or procedural changes

Find training examples at Language Access Fundamentals (Welcoming America, 2024) and Communicating With Multilingual Populations: Language Access Toolkit [PDF] (Global Wordsmiths, n.d.).

6. Quality assurance and monitoring: Ongoing quality control measures and processes ensure that language assistance services are accurate and that language access plans are effective (Langdon & Saenz, 2016; U.S. Department of Health and Human Services, 2024).
   • Regular reviews of interpreter and translator performance; working with certified language professionals; tracking interpretation and translation errors while analyzing their impact; and collecting staff and patient feedback through surveys, interviews, or feedback forms.
   • Routine audits of language access components by reviewing policies, procedures, and service delivery to ensure compliance with standards and regulations.
   • An improvement process for monitoring the implementation of the language access plan and its effectiveness, where feedback and audit results influence ongoing enhancements to those plans and related services.
7. Community engagement: Gathering community input is essential for developing effective and inclusive language access plans. Providers and agencies can collect consumer and community feedback through the following methods:
   • Suggestion boxes, online forms, or hotlines where community members can provide feedback or input.
   • Public forums and listening sessions, focus groups, and surveys to engage with community members and organizations to better understand needs, strengths, and concerns.
   • Community advisory boards, which can provide ongoing feedback and guidance on communication and language access materials, processes, and effectiveness.
   • Partnerships with community organizations, which can also facilitate opportunities to gather feedback from their members.

For more information, see Conducting Public Forums and Listening Sessions (Head Start, 2025).

8. Funding and resources: Agencies and service providers consider various funding sources and strategies to support language access planning and implementation, such as the following:
   • Internal budget allocation, private grants and donations, and/or community partnerships for hiring qualified interpreters and translating materials.
   • Federal and state funding opportunities, such as federal grant, government, and/or program funding to support language access programs.
   • Some state Medicaid agencies reimburse language services, but most third-party payers do not pay for the services of an interpreter.

For more information, see Medicaid and CHIP Reimbursement Models for Language Services: 2024 Update (Youdelman, 2024) and Federal Laws and Policies to Ensure Access to Health Care Services for People With Limited English Proficiency [PDF] (National Health Law Program, 2018).

By addressing these components of language access planning, service providers and agencies can ensure they meet legal requirements and provide equitable access to services for multilingual individuals.

Types of Interpreting, Transliteration, and Translation

The clinician should consult the patient and care partner to determine the mode of communication or accommodation that best suits each clinical interaction. This choice may vary depending on the type of clinical encounter (i.e., meeting, counseling, assessment, intervention) and the setting protocols. The patient’s equitable access to services includes the following:

• making an appointment for services
• completing paperwork and case history forms
• participating in face-to-face or virtual meetings
• receiving written reports
• interacting during assessment and intervention

During service provision, clinical encounters with the patient and care partner may require different types of interpreting, transliteration, and translation services.

Types of Interpreting

Interpreting can be either simultaneous or consecutive. These two types of interpreting are described below.

Simultaneous interpreting—the interpreter communicates what a speaker or signer is saying into another language while they (the speaker or signer) continue to speak or sign. This method helps meetings run smoothly without interruptions, especially in clinical settings or when most participants speak the same language. Simultaneous interpreting is used more with signed languages than with spoken languages because when multiple people in a group are speaking and interpreting at the same time, it can cause auditory interference for the listener (Langdon & Saenz, 2016).

Consecutive interpreting—the interpreter (a) waits for the speaker to finish a section of speech and then (b) communicates the message during a pause. The interpreter breaks the message into manageable segments to ensure that the listener can clearly understand the message in the target language. Consecutive interpreting is used more during assessments and interventions for spoken language. Both spoken- and sign-language interpreters may use this method when a patient provides a lot of information at once to ensure full understanding and accurate translation. It is also preferred for patients with cognitive challenges (Langdon, 2002).

Interpreters, on site or by telephone, may switch between consecutive and simultaneous interpreting based on the needs of the clinical interaction and the communication goals.

Types of Transliteration

The three types of transliteration—oral, cued speech, and sign—are described below.

Oral transliteration—the transliterator mouths words clearly so that people who are D/HOH and skilled in speechreading can understand what is being said by watching the transliterator’s face, gestures, body language, and lips. Oral transliterators may choose to rephrase a message with words that are more visible on the lips when possible. They may also “voice” for individuals who are D/HOH (Registry of Interpreters for the Deaf, 2007).

Cued speech transliteration—the transliterator uses handshapes and movements in different locations near the mouth to depict sounds used in spoken language. The clinician generally uses cued speech to support speechreading by providing a visual representation for the sounds in a language. However, it is not a form of sign language (National Cued Speech Association, 2006).

Sign transliteration—the transliterator uses signs in the word order of the target spoken language (e.g., signed English) to convey the spoken message for people who are D/HOH who do not use a formal sign language (e.g., American Sign Language).

Types of Translation

Not all spoken and manually coded languages, including American Sign Language, have a written form. The various types of translations are discussed below.

Machine translation—text-based automated translation that provides instant translations between languages without the assistance of, or review by, a qualified human translator (Section 1557 of the Affordable Care Act [2024]). According to Section 1557 of the Affordable Care Act, a qualified human translator must review the machine translations in any of the following situations (89 F.R. 37522):

• The underlying text is critical to the rights, benefits, or meaningful access of a person with “limited English proficiency.”
• Accuracy is essential.
• The source documents or materials use complex, nonliteral, or technical language.

Prepared translation—the translator prepares the written version of a document, such as a letter or report, in advance. Enough time must be allowed based on task complexity. For instance, an appointment reminder may not take long, but a short assessment piece could take much longer, depending on the focus of the assessment. The clinician should be available to answer the translator’s questions about the materials. Prepared translation may be the most common form of translation in clinical settings.

Prepared translation can be used to prepare instructions, assessments, treatment, and educational materials in advance. Prepared translation may also be necessary when the clinician is providing written reports or documentation of assessments and progress, such as IEPs or discharge reports.

Sight translation—the translator provides a spoken or signed translation while reading a written document in a clinical encounter reserved for more immediate and spontaneous needs. This approach is not a reasonable option for informed consent, other legal documents, or formal assessment measures. The clinician may use sight translation when they decide that certain materials may be more appropriate for a clinical encounter than other types of translations that they had previously prepared (Langdon & Saenz, 2016). See the Impromptu Translation section of this document for more information.

Role of Cultural and Linguistic Brokers

Interpreters, transliterators, and translators may serve in the role of a cultural broker (Torres et al., 2015) or a linguistic broker (Orellana et al., 2014). Audiologists, SLPs, audiology assistants, and speech-language pathology assistants can also serve as cultural or linguistic brokers if they have relevant knowledge and experience with the patient and care partner’s cultural and linguistic background. Visit ASHA’s Practice Portal page on Multilingual Service Providers for more information.

Cultural broker—a person who knows about the setting’s culture as well as the patient’s culture and/or speech-language community. The cultural broker is someone who can build trust between individuals or groups of different cultural systems. The broker passes cultural and community-related information between the patient and the clinician to help people effectively navigate health, education, or human services systems (Pang et al., 2019).

Linguistic broker—a person who knows about the setting’s language and the patient’s language community or communication environment. A linguistic broker can provide valuable information about language and sociolinguistic norms.

A cultural or linguistic broker can provide the following skills and knowledge:

• grammaticality and/or intelligibility judgments, indicating whether the patient’s language and speech sound production is consistent with the norms of that speech community or communication environment
• information on the language socialization patterns (i.e., use of language in socially appropriate ways based on the culture) of that speech community or communication environment
• information on other areas of language, including semantics and pragmatics
• ability to interpret and repair language and structure within language systems that do not translate literally from one community to the other

Roles and Responsibilities of Audiologists, SLPs, and Assistants

When collaborating with language assistance providers, audiologists and SLPs remain responsible for planning the session, selecting culturally and linguistically relevant materials, and appropriately administering assessment and treatment. The interpreter or transliterator assists the clinician in gathering the appropriate data and provides language support for services appropriate to the patient. For additional roles and responsibilities for multilingual service delivery, visit ASHA’s Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Appropriate roles and responsibilities of audiologists, SLPs, and assistants (as their respective scope of practice allows) when collaborating with an interpreter, a transliterator, or a translator include the following:

1. Uphold federal guidelines for ensuring language access in health care and educational settings.
2. Identify the appropriate spoken and/or signed language(s) of service for patient and their care partners—including the preferred language for meetings, clinical interactions, and written documentation.
3. Recognize that not all spoken or manually coded languages have a written form.
4. Use plain language principles to ensure that all messages, especially written information, are clear and concise (Alani et al., 2024). See ASHA’s resources on health literacy and communication access.
5. Advocate for access to—and sustainable funds for—an interpreter, a transliterator, or a translator.
6. Seek an interpreter, a transliterator, or a translator who has knowledge, skills, and relevant experience. See the Selecting an Interpreter, Transliterator, or Translator section of this document for more information.
7. Seek information on the features and developmental characteristics, when available, of the language(s) and/or dialect(s) that are spoken or signed by the patient or care partner.
8. Obtain information on the linguistic community to identify significant cultural and linguistic influences.
9. Establish collaborative relationships with cultural or linguistic brokers, interpreters, transliterators, and translators to maximize the effectiveness of services by doing the following tasks:
   1. Providing the goals and intent of the session to the interpreter, transliterator, or translator.
   2. Scheduling additional time in each session to allow for a briefing, an interaction, and a debriefing.
   3. Making advance arrangements to ensure appropriate physical accommodations (e.g., space, lighting, noise) necessary for a successful collaboration. Physical accommodations may include placement of phone, computer, and/or video screen to ensure visibility and audibility during remote sessions.
   4. Arranging for the translation of documents written in unfamiliar languages—to ensure that clinicians know the content of the documents. Note that translation of written material from one language to another may alter the document’s intent and overall readability.
10. Verify the cultural appropriateness of assessment and treatment materials, and review potential bias, as applicable. Clinicians also review prompts in assessment materials for linguistic influences of an additional language and consult with language assistance providers to review phonetic information and potential syntactic influences.
11. Evaluate and integrate technologies to promote language access, as appropriate.
12. Maintain appropriate professional relationships among the clinician; the patient and care partner; and the interpreter, transliterator, or translator (ASHA, 2023b).

The ASHA Code of Ethics (Principle I, Rules A, B, and C; Principle II) provides the baseline for the quality of services that the clinician is expected to provide. These expectations are as follows:

• Clinicians must do their best to ensure that the services provided are appropriate.
• Clinicians must not discriminate in service delivery based on age; citizenship; disability; ethnicity; gender; gender expression; gender identity; genetic information; national origin, including culture, language, dialect, and accent; race; religion; sex; sexual orientation; or veteran status.
• Clinicians must make every effort to become familiar with all of the patients’ languages (e.g., language structures, phonemic inventory, how translation/interpretation may impact the message).
• Clinicians must provide all services competently and use every resource, including interprofessional collaboration, to ensure that they provide high-quality services.

Selecting an Interpreter, Transliterator, or Translator

In addition to federal requirements for education, training, certification, and/or licensure of language assistance providers, state and employer policies may vary. Some state laws and regulations impose additional standards and requirements for working in specialized settings (e.g., legal, medical, and educational), particularly when serving individuals who are D/HOH. See State-by-State Regulations for Interpreters and Transliterators for requirements for interpreters and transliterators for individuals who are D/HOH.

Employers such as school districts, courts, and health care systems may also have interpreting aptitude tests, performance assessments, or boards that evaluate interpreters before they are hired. These employers may also require credentialing from a state or national organization. A growing number of state and national associations have professional standards and certification for trained interpreters. Trained and/or certified professionals have codes of ethics within their professions that they are expected to maintain. See the Registry of Interpreters for the Deaf, National Council on Interpreting in Health Care [PDF], American Translators Association [PDF], and National Association of Interpreters in Education.

Language assistance providers can effectively bridge communication gaps and provide accurate, culturally appropriate translations with the following knowledge and skills (California Speech-Language-Hearing Association, 2017):

• Linguistic aspects: The interpreter, transliterator, or translator has a high level of fluency and understanding in the target languages. They are aware of regional and social variations in signed and spoken languages. They have familiarity with specific terminology in the relevant field (e.g., audiology, speech-language pathology, education, medicine). They can accurately and clearly convey messages without adding, omitting, or altering the meaning.
• Personal aspects: The interpreter, transliterator, or translator can maintain a professional and collaborative demeanor. They adhere to ethical standards and ensure all information remains confidential. They have strong communication and interpersonal skills to effectively interact with patients and professionals. They understand the basic principles of assessment and/or intervention and can provide context to the patient and their care partners to understand clinical objectives.
• Cultural aspects: The interpreter, transliterator, or translator is familiar with the patient’s and/or care partner’s culture or communicative environment. They respect and respond to cultural differences and nuances. They are sensitive to cultural influences and minimize biases. They act as cultural mediators to facilitate understanding and communication.

Most of the time, organizations may have established relationships—such as a referral list—that specify which companies or people can serve as an interpreter, a transliterator, or a translator. A clinician may or may not have the opportunity to provide input on the selection for the initial meeting with the patient or care partner. However, to the maximum extent possible, employers are encouraged to use the same interpreter, transliterator, or translator for multiple encounters, so that the clinician may establish a familiar relationship and provide knowledge of the work process.

Additional Professionals Who Can Serve as Interpreters, Transliterators, or Translators

Individuals who serve as interpreters, transliterators, or translators include

• professionals with specific training in this area (as defined by Section 1557 of the Affordable Care Act),
• multilingual assistants,
• multilingual professional staff from a health or education discipline other than communication sciences and disorders, and
• multilingual staff available within the facility but outside of health or education disciplines.

The list above, arranged in approximate order of preference, does not account for the unique variables inherent in clinical interactions. Interpreters have unique skill sets and expertise. Clinicians collaborate with them whenever possible, as appropriate, in multilingual service delivery. Multilingual audiology and speech-language pathology assistants are not interpreters. Audiology and speech-language pathology assistants may be able to interpret to meet an unanticipated need.

Consult ASHA’s Practice Portal pages on Multilingual Service Providers, Audiology Assistants, and Speech-Language Pathology Assistants.

Multilingual assistants and professional staff must consider their linguistic proficiency in the languages being used, including (a) their proficiency in the local dialect of the language(s) being used by the patient and their care partner and (b) their own knowledge and skills for interpreting, transliterating, or translating. Dialectal mismatches—such as a Spanish-speaking individual from Mexico interpreting for a Spanish-speaking patient from Spain or Argentina—may result in inaccurate interpretations, inaccurate translations, and/or cultural misunderstandings (Ostergren, 2014).

Family Members or Friends Serving as Interpreters, Transliterators, or Translators

The need for an interpreter, a transliterator, or a translator may influence a clinician’s ability to diagnose, treat, and seek reimbursement for services. Therefore, it is best to work with trained interpreters, transliterators, and translators when possible. On limited occasions, there may be reasons why a family member or friend serves as an interpreter, a transliterator, or a translator—either due to patient preference or because all other efforts to locate an appropriate language assistance provider have been exhausted. A facility may be unable to locate a person who is able to meet the linguistic needs of the patient. For example, family or community members may be the only source of information for a less commonly known language, such as Pirahã, an Amazonian language for which access to language assistance providers is scarce.

Family or friends acting as interpreters, transliterators, or translators may present potential conflicts (Iqbal & Crafter, 2023). The reliability of language assistance may be compromised because of potential conflicts of interest and limited training of the family member or friend. It is important to be mindful of risks in high-stakes situations, such as mediation, evaluations, or situations where cognitive capacity might be in question.

When considering working with family members or friends in this role, the clinician reviews the following factors:

1. Is this a session for assessment or a session for treatment?
2. What is the intent of the message? Will you be using it to share sensitive information, such as a diagnosis, or to provide intervention techniques, such as safe swallowing strategies?
3. How old is the family member or friend providing the interpretation? What is the position and role of that individual within the family structure, their overall linguistic ability, and their comfort serving in this role? For example, minors may not possess the emotional maturity and sensitivity necessary to serve in the role of assisting family members in the provision of services.
4. What are your organization’s requirements for providing language assistance services?

There are legal and ethical considerations for asking family members or friends to serve as interpreters, transliterators, or translators. See the State and Federal Legislation section and the Ethics section of this document for more information.

Collaborating With the Interpreter or Transliterator

The clinician and the interpreter or transliterator collaborate using the briefing–interaction–debriefing framework (Langdon, 2002). Successful collaboration is inherent to successful service delivery (Alani et al., 2024) and is based on a shared understanding of the goals established by the clinician (Gardner & Love, 2021). This can be achieved by properly preparing the interpreter or transliterator for what to expect from the assessment or treatment session. The audiologist or SLP is responsible for the assessment or treatment session and is actively engaged in the encounter with the patient and interpreter. After the assessment or treatment session, the clinician and the interpreter or transliterator should discuss how the session went to be sure that no issues arose that need to be discussed (Langdon, 2002; National Council on Interpreting in Health Care, 2024).

Key Considerations Before Working With Untrained Language Assistance Providers

Collaborating with an interpreter or a transliterator who is untrained in the communication sciences and disorders setting may influence a clinician’s ability to diagnose, treat, and seek reimbursement for services. Untrained interpreters or transliterators may unintentionally misrepresent a meaning when converting messages into another language and/or reporting patient responses, particularly if they are unaware of the purpose of the exercise or assessment. Untrained interpreters and transliterators may also influence patient responses or understanding of clinician questions. In some cases, seemingly small errors can change the meaning of a question or response and can have drastic effects on outcomes. For this reason, it is best to work with a trained interpreter or transliterator when possible. Because of the specific nature of the fields, a clinician will need to provide training prior to the session to ensure the best possible outcomes during clinical sessions and should periodically check in to assist in the effective delivery of services (Langdon & Saenz, 2016).

Documentation of Services

Reports and submissions for insurance claims note when a clinician works with language assistance providers and the impact of that collaboration on assessment and intervention findings. Documentation should also indicate the use of translated materials. This documentation provides an accurate record of clinical interaction and a legal record of the services provided. It also provides evidence of ethical conduct, consistent with Principle of Ethics I, Rules of Ethics B, C, and Q (ASHA, 2023b). See ASHA’s Practice Portal pages on Documentation of Audiology Services, Documentation in Health Care, and Documentation in Schools.

See also Perspectives of the ASHA Special Interest Groups articles—Guidance on the Effective Collaboration With Interpreters and Translators in Speech-Language Pathology (Alani et al., 2024) and Working With Interpreters to Support Students Who Are English Language Learners (Langdon & Saenz, 2016)—for additional information on how to debrief with an interpreter before and after your session.

Before the Clinical Interaction With the Patient and Their Care Partners (Briefing)

Clinicians meet with the interpreter or transliterator in advance to allow for adequate preparation time, when possible. Clinicians take the following actions before the session to ensure a successful collaboration (Langdon, 2002):

Setting Expectations With the Interpreter and Transliterator

1. Discuss the format and purpose of the clinical encounter by explaining who will participate, what will be accomplished, and for what purpose.
2. Determine whether the interpretation will be consecutive or simultaneous.
3. Review and learn greetings and the appropriate pronunciation of names in the family’s language.
4. Provide written information prior to the meeting, including proper names of those at the meeting, technical terms and abbreviations, copies of visual references, and topics to be covered.
5. Explain confidentiality policies pertaining to HIPAA regulations, the Family Educational Rights and Privacy Act, and the ASHA Code of Ethics (ASHA, 2023b). Document that these policies have been explained and accepted.
6. Discuss prompts or cues that the interpreter or transliterator can use if the clinician speaks too quickly or too softly or if the clinician’s speech or meaning is unclear.
7. Prepare language assistance providers for careful listening and note-taking when working with patients who may present with difficulty in comprehension, expression, speech sound production, or other areas of communication. Individuals with communication disorders may display features that add an additional level of complexity to the interaction (Alani et al., 2024).

Reviewing Assessment and/or Treatment Procedures

1. Review the goals and procedures of the session or clinical interaction, including discussion of
   1. whether gestures may or may not be used,
   2. the possible influence of vocal intonation,
   3. the presence of feedback to the patient, and
   4. other cues that may inadvertently influence the session in unanticipated ways.
2. Review assessment administration procedures or intervention techniques. Ensure that the interpreter or transliterator is aware of the purpose of such procedures/techniques to elicit the desired type of response.
3. Provide a copy of assessment prompts, in advance, to avoid any sight translations.
4. Explain to the interpreter or transliterator why and how various activities and exercises assist the patient. Providing context for an activity is often helpful in accomplishing goals.
5. When applicable, discuss the impact that finger spelling may have on assessment results and review possible differences in the conceptual accuracy of some signs relative to spoken language.
6. Review procedures for capturing the patient’s verbal and behavioral responses.

During the Clinical Interaction (Interaction)

Clinicians take the following actions during the session:

Introduction and Roles

1. Introduce the clinician and the interpreter or transliterator to the patient in the language that the patient uses.
2. Describe the role of the clinician and the interpreter or transliterator and clarify expectations.
3. Talk directly to the patient and ensure comprehension of diagnosis, prognosis, and treatment recommendations—as the clinician would do with all patients.

Session Management

1. Review and discuss the process for data collection.
2. Schedule or offer breaks, as appropriate, to maximize engagement and minimize fatigue.

Communication Guidance

1. Use short, concise sentences.
2. Avoid the use of idiomatic expressions. These expressions may not have the same meaning across languages.
3. Pause frequently to allow the interpreter or transliterator enough time to convey information accurately.
4. Avoid having the clinician’s back to the interpreter or transliterator and the patient or care partner when speaking.
5. Periodically check with the interpreter or transliterator to see if the clinician’s speech is too fast, too slow, too soft, or too unclear.
6. Be aware of nonverbal body language and gestures that may be considered offensive to the patient or care partner.
7. Observe nonlinguistic behaviors to supplement interpreted or transliterated information.

Cultural and Linguistic Considerations

1. Recognize that the role of the interpreter or transliterator is to convey meaning—and, sometimes, there is not an equivalent word that can be translated. For example, in familiar word pairings used in a conceptual activity, the term “peanut butter and jelly” may not be culturally relevant to the patient or care partner.
2. Allow enough time for the interpreter or transliterator to organize information and recognize that variations in narrative discourse across languages influence the amount of information required to accurately convey intent.
3. Understand that words that express feelings, attitudes, and qualities may not have the same meaning when directly interpreted or transliterated.
4. Avoid oversimplification of diagnoses, recommendations, and other relevant information.
5. Provide written materials in the patient’s or care partner’s preferred written language.

After the Clinical Interaction (Debriefing)

The clinician takes the following actions after the session (Langdon, 2002; Langdon & Saenz, 2016):

1. Review the patient’s responses to test stimuli, analyze language samples, and discuss any difficulties that the interpreter or transliterator observed. Verify whether the patient’s performance may have been influenced by cultural and/or linguistic variables.
2. Gather feedback from the patient and their families about the quality of language assistance services.
3. Discuss successes, difficulties, feedback, or concerns. Discuss ways to maintain or improve language assistance services for multilingual service delivery in future encounters.
4. Collaborate with language assistance providers to share carryover activities with family members to support the patient’s communication in their home and community using their language(s).

For more details about assessment and treatment considerations for multilingual populations, visit ASHA’s Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Working With Translators

Special considerations for effective collaboration with translators are as follows:

• Confirming that the spoken languages have a written form.
• Confirming whether the preferred written language of a patient and their care partner is the same as their preferred spoken language.
• Allowing time for the translator to prepare the translation and ask questions, particularly as it pertains to medical terminology and recommendations.
• Using plain language techniques for source materials to increase accessibility of translated documents (Alani et al., 2024).

Dialectal differences may influence translation. To the maximum extent feasible, ensure that documents are written in a way that is the most universally understood by speakers of different dialects of a written language.

All vital written documentation provided to the care partner is translated into the patient’s and care partner’s preferred language.

Provide all legal documents and highly relevant materials to the translator ahead of time. In a research setting, informed consent is presented to each human subject “in language understandable to the subject” (Federal Policy for the Protection of Human Subjects, 2001). Informed consent is documented in writing in most situations.

Impromptu Translation

Clinicians provide sufficient time for the translator to become familiar with these documents. Not all spoken or signed languages have written forms of communication.

Prepared or on-site translation of formal assessments that have been standardized on English-speaking populations may provide the opportunity to gather information in a structured manner. However, the clinician must critically evaluate the validity of the translated materials. For example, speech sound elicitation materials may not elicit the same sounds, and allophonic variation will differ across languages. For example, subject omission is acceptable in Spanish but not English, so in a sentence repetition task, take great care in how the data are used. Written permission is to be obtained from the test publisher before test materials can be translated either for a clinician’s individual use or for dissemination of the translated version of the test for use on a wider scale (i.e., clinical program, district, or research group). In the circumstances above, it is not appropriate to report standard scores.

Clinicians are cautious about using technology for on-site translation. Software programs frequently look for verbatim substitutions and do not offer professional, reliable results. Interpreting and translating may not always be a word-for-word substitution but, instead, may require more or fewer words to communicate an intended message as well as complete syntactic restructuring of sentences or even full paragraphs to maintain cohesion and coherence. See the definition of machine translation in the Types of Translation section of this document.

Paying for Language Assistance Services

Patients are not expected to pay out of pocket for language assistance services to ensure access to care. Several laws and regulations mandate that organizations receiving public funding, such as Medicaid/Medicare or IDEA funding, provide and arrange for meaningful language access. Those organizations are responsible for the funding of a language assistance provider, as needed.

Agencies, administrators, and service providers can leverage the following funding sources and strategies to pay for language assistance services and ensure that all individuals, regardless of language ability, have access to essential services. Here are some key methods:

• Federal grants and program funding: Federal funding, such as Medicaid and the Children’s Health Insurance Program (CHIP), helps states and health providers pay for language services (Centers for Medicare and Medicaid Services, n.d.). See the National Health Law Program’s Medicaid and CHIP Reimbursement Models for Language Services [PDF] for options available in your state.
• State and local government funding: Organizations can allocate IDEA funding and additional state funds for language assistance services.
• Private grants and donations: Organizations can seek grants from foundations that support health equity, education, and/or community services.
• Third-party (or insurance) reimbursement: Currently, most third-party payers, except for a few state Medicaid agencies, do not pay for the services of an interpreter. However, some third-party payers and insurers may require documentation for how a patient’s language or communication needs will be addressed prior to sending reimbursement.
• Internal budget allocations: Agencies can allocate a portion of their internal budgets to fund language assistance services. This might include hiring bilingual staff, contracting with language service providers, and investing in translation technology.
• Community partnerships: Collaborating with community organizations that serve specific language communities can help agencies share resources and reduce costs. These partnerships can also enhance the effectiveness of language access services by leveraging community expertise and trust.

Contracting

Clarify the party responsible for payment of interpreter, transliterator, or translator services when providing contracted services. For example, the facility may be responsible for providing appropriate accommodations for language assistance services, or the clinician may need to list language assistance services as a line item in the clinician’s services.

Additional considerations for contracting interpreters, transliterators, or translators are as follows:

• Evaluating their qualifications and extent of experience.
• Acknowledging their communication styles.
• Ensuring the language assistance provider can convey the information accurately, impartially, confidentially, and with cultural responsiveness.

Technology

Technology offers opportunities for individuals to access interpretating, transliteration, and translation services. The list below is not exhaustive:

• Telephone or video relay/video remote interpreting services offer access to off-site interpreters or transliterators. Clinicians ensure that equipment will facilitate clear connections throughout the session and optimize communication.
• Communication Access Realtime Translation (CART; also known as “Computer Assisted Realtime”) transcribes and instantaneously captions spoken language to relay messages. CART mainly provides access to services for individuals who are D/HOH.
• Many apps, devices, and programs allow for immediate translation. These tools do not meet federal requirements of a qualified interpreter (89 F.R. 37522). See the Types of Translation section of this document for additional considerations of technology and translation.

Technology may be used to facilitate carryover and recall of strategies and techniques. Smartphones provide an opportunity to record spoken language and video signed languages to allow patients and care partners to revisit clinical recommendations.

Refusal of Language Assistance Services

At times, patients and/or care partners may refuse the assistance of an interpreter or a transliterator. Clinicians consult with patients and caregivers/care partners on the value of working with the interpreter or transliterator so that (a) the patient and the care partner can fully participate in health services and care and (b) the clinician can obtain the most accurate data. If language assistance services are refused, the clinician documents the following:

• the patient’s ability to understand
• the name of the patient and the name of either (a) the care partner or (b) the power of attorney
• relationship to the patient
• the identification number and/or name of the interpreter or transliterator employed to inform the patient of their rights

A signed release statement should be collected in cases where such services are declined, which includes the reason for the refusal. The service provider informs the patient and care partner of the benefits of language assistance services and the potential adverse consequences of not having such services. The service provider also documents the above conversation.

ASHA Resources

• Communication Access
• Health Literacy
• IDEA Part B: Culturally and Linguistically Diverse Students
• IDEA Part B: Interpreting Services for the Deaf or Hard of Hearing
• IDEA Part C: Cultural and Linguistic Diversity
• Issues in Ethics: Cultural and Linguistic Competence
• Meeting the Needs of Limited English Proficiency Patients
• Prohibitions Against Discrimination Under ASHA’s Code of Ethics and Enforcement by the Board of Ethics
• Request to Translate and Distribute ASHA Content
• SIG 16 Perspectives: Working With Interpreters to Support Students Who Are English Language Learners
• SIGnatures: Integrating an Interpreter
• Understanding Language Access Requirements for Audiologists and SLPs

Related Resources

This list of resources is not exhaustive. The inclusion of any specific resource does not imply endorsement from ASHA.

• Checklist for General Effective Communication
• Classroom Interpreting
• Communication Aids and Services as Required by Law
• Despite new Executive Order, Language Access Is Still the Law!
• Guide to Privacy and Security of Electronic Health Information [PDF]
• Health Insurance Portability and Accountability Act
• Language Access Planning | LEP.gov
• Limited English Proficiency (LEP) | HHS.gov
• National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care
• Registry of Interpreters for the Deaf
• Section 1557 of the Affordable Care Act
• Section 504 of the Rehabilitation Act of 1973
• Summary of State Law Requirements Addressing Language Needs in Health Care
• Testing, Evaluation, and Certification Unit for Cued Language Transliterators
• The National Board of Certification for Medical Interpreters
• Tips for Working with Sign Language Interpreters [PDF]
• Title VI of the Civil Rights Act of 1964
• Working Effectively With an Interpreter [PDF]

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Al Shamsi, H., Almutairi, A. G., Al Mashrafi, S., & Al Kalbani, T. (2020). Implications of language barriers for healthcare: A systematic review. Oman Medical Journal, 35(2), Article e122. https://doi.org/10.5001/omj.2020.40

American Speech-Language-Hearing Association. (n.d.-a). IDEA Part B: Culturally and linguistically diverse students. https://www.asha.org/advocacy/idea/idea-part-b-issue-brief-culturally-and-linguistically-diverse-students/

American Speech-Language-Hearing Association. (n.d.-b). IDEA Part C: Cultural and linguistic diversity. https://www.asha.org/advocacy/idea/idea-part-c-issue-brief-cultural-and-linguistic-diversity/

American Speech-Language-Hearing Association. (2017). Issues in ethics: Cultural and linguistic competence. https://www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/

American Speech-Language-Hearing Association. (2023a). Ad Hoc Committee on Bilingual Service Delivery: Competencies, expectations, and recommendations for multilingual service delivery [Final report]. https://www.asha.org/siteassets/reports/ahc-bilingual-service-delivery-final-report.pdf [PDF]

American Speech-Language-Hearing Association. (2023b). Code of ethics [Ethics]. https://www.asha.org/policy/

Americans with Disabilities Act of 1990, Pub. L. No. 101-336, 42 U.S.C. § 201 et seq. (1990).

AMN Healthcare. (2021). 2021 Healthcare World Language Index [White paper]. https://www.amnhealthcare.com/amn-insights/whitepapers/healthcare-world-language-index/

California Speech-Language-Hearing Association. (2017). Collaborating with interpreters and translators [Position paper]. https://www.csha.org/collaborating-with-interpreters-and-translators-2017/

Medicaid. (n.d.). Translation and interpretation services. Centers for Medicare and Medicaid Services. https://www.medicaid.gov/medicaid/financial-management/medicaid-administrative-claiming/translation-and-interpretation-services

Civil Rights Act of 1964, Pub. L. No. 88-352, 20 U.S.C. § 241 et seq. (1964).

Dietrich, S., & Hernandez, E. (2022). Language use in the United States: 2019. American Community Survey Reports. https://www.census.gov/library/publications/2022/acs/acs-50.html

Equal Educational Opportunities Act of 1974, Pub. L. No. 93-380, 20 U.S.C. § 1701–1758 (1974).

Federal Policy for the Protection of Human Subjects, 45 C.F.R. § 46 (2001).

Gardner, L., & Love, J. (2021). Equity through language access: Best practices for collaborating with interpreters. National Education Association. https://www.nea.org/resource-library/equity-through-language-access-best-practices-collaborating-interpreters

Global Wordsmiths. (n.d.). Communicating with multilingual populations: Language access toolkit. https://www.hsfoundation.org/wp-content/uploads/LanguageToolkit-digital_May-202325.pdf [PDF]

González-Cestari, T. (2025, March 13). New Executive Order on official languages: What it means for language access. Martti. https://www.martti.us/articles/new-executive-order-on-official-languages-what-it-means-for-language-access

Head Start. (2025). Conducting public forums and listening sessions. https://headstart.gov/program-planning/article/conducting-public-forums-listening-sessions?redirect=eclkc

Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 42 U.S.C. § 201 et seq. (1996).

Iqbal, H., & Crafter, S. (2023). Child language brokering in healthcare: Exploring the intersection of power and age in mediation practices. Journal of Child and Family Studies, 32, 586–597. https://doi.org/10.1007/s10826-022-02376-0

Individuals with Disabilities Education Act of 1990, Pub. L. No. 101-476, 20 U.S.C. § 1400 et seq. (1990).

Langdon, H. W. (2002). Interpreters and translators in communication disorders. Thinking Publications.

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Collaborating With Interpreters, Transliterators, and Translators page:

Primary Version

• Nancy Castilleja, MA, CCC-SLP
• Linda Jarmulowicz, PhD, CCC-SLP
• Ellen Kester, PhD, CCC-SLP
• Katherine Langan, PhD
• Henriette Langdon, PhD, CCC-SLP
• Edgarita Long, PhD, CCC-SLP
• Karen Muñoz, EdD, CCC-A
• Karin Ruschke, MA
• Terry Saenz, PhD, CCC-SLP
• Brenda Seal, PhD, CCC-SLP
• Kenneth Wolf, PhD, CCC-A

Subsequent Versions

• Andrea Liacouras, AuD, CCC-A (2025)
• Marcella McCollum, EdD, CCC-SLP (2025)

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times, a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Collaborating with interpreters, transliterators, and translators [Practice portal]. https://www.asha.org/practice-portal/professional-issues/collaborating-with-interpreters/