Professional Services: Work Request Form

First Name:
Last Name:
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.