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Professional Services: Work Request Form

First Name:
Last Name:
Title:
Company:
Association Affiliation:
Telephone Contact:
Email address:
Request Submission Date:


Purpose for Form Submission:
(Check all that apply)

Service Code: Add Code Request
Service Code: Change Code Description Request
Service Code: Delete Code Request
Service Code: HCPCS
Service Code: CPT
Companion Guide (Compilation of Service Transaction Segments)
Companion Guide: Addition
Companion Guide: Change
Companion Guide: Deletion

Description of Submission:

Clinical/Business Justification
(required if Change Request; optional if Inquiry):

Provide national statistical data regarding the submission.



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