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.