OUR PROCESS >
Filing claims, identifying home modification needs and implementing changes
OUR PROGRAM >
Our trained specialists perform outstanding home modifications with quality assurance
YOUR SOLUTION >
Home modifications performed with ease and cost efficiency

Home Modification Claim Assignment Online Form

  Contact Information:  
   
Company
Primary Contact
Phone
Fax
Email
Major Case Unit Supervisor
Supervisor Phone Number
Supervisor Email
* indicate required fields

  Injured Worker Information:  
   
Claim Number
First Name Last Name
Phone Number
Date of Birth (mm/dd/yyyy)
Gender Height (ft/in) Weight
* indicate required fields

  Location Information:  
   
Address
City State Zip
Email
* indicate required fields

  Injury/Diagnosis Information:  
   
Diagnosis
Date of Injury (mm/dd/yyyy)
Date of Discharge (mm/dd/yyyy)
Doctor Orders/Scripts
  
You can send orders with this form or fax to: (501) 325-4324.
Other Medical Conditions
* indicate required fields

  Primary Contact Information:  
   
First Name Last Name
Phone
Relationship

  Issue(s) requring home modification:  
   
Issues
* indicate required fields

  Service Required:  
   
Level 1
I need a contractor and I want DCC to review the scope and estimate and if authorized, I want DCC to have full project oversight. (If no scope is included, there will be a hourly charge for scope development when required.)
Level 2
I need a DCC accessibility specialist to complete a skilled on site home assessment, nothing more is needed at this time.
Level 3
I need a DCC accessibility specialist to complete a skilled on site home assessment, assign a contractor and then if authorized, have complete project oversight.
Level 4
I have a special request that does not fit the other categories.
Explain

  Special Instructions/Comments:  
   
Instructions/Comments