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Filing claims, identifying home modification needs and implementing changes

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Home Modification Claim Assignment Online Form

Assignment From:

Company:

Primary Contact

Phone: Fax: Email:

Injured Worker:

Claim Number:

Last Name

First Name

Phone Number

D.O.B.: Height: Weight:

Location:

Street:

City: State: Zipcode:

Diagnosis:

Date of Injury

Anticipated Date of Discharge

Other Medical Conditions

Injured Workers Primary Contact:

Last Name:

First Name:

Phone Number:

Relationship:

Service Requested:

Level 1 -

I only need a contractor, no oversight or DCC involvement is necessary

Level 2 -

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

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 need a DCC accessibility specialist to complete a skilled on site home assessment, nothing more is needed at this time

Level 5 -

I have a special request that does not fit the other categories.

Explain

Instruction / Comments: