Request For Manual Change Form

DWC Manual Change Form Revised: December 2009 COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS' CLAIMS REQUEST FOR MANUAL CHANGE FORM requests that the Department of Workers' Claims please make a (Company Name) manual change to the field checked below for (Employee Name and SSN) . Date of Injury (DN 31) Nature of Injury (DN 35) Requires a detailed explanation to be faxed or mailed with this form. Social Security Number (DN 42) Date of Death (DN 57) List the change you wish to make in the space below. Only one manual change can be requested per form. Dept. of Workers' Claims Agency Claim Number DN# __________ Currently Contains Change To ___________________________ I ______________________________________________________ on this date _________________ approve the change being (Signature of approving authority) (Date signed) requested and have submitted documentation explaining the need for the change to the field that requires said documentation. For confirmation of this change, I can be reached at: (Email and/or telephone number) . A Manual Change Form is required to change the Date of Injury; Nature of Injury; and Social Security Number due to the fact that these are locked fields in the DWC electronic database. A Manual Change Form is also necessary to make a change when a Date of Death has been reported in error. Your signed form may be faxed or mailed. Changes will be made by the DWC staff once the signed form is received. The Manual Change Form must be followed by an 02 transaction containing the updated fields. For faxed forms, the 02 can be transmitted immediately. If mailed, please allow five days before submitting the 02 change. Forms not signed will be returned for signature , thus delaying the change requested. This form must be completed and submitted by the Carrier or TPA. Forms submitted by anyone other than the Carrier or TPA will not be accepted. Please FAX this form to the EDI Se ction: (502) 696-5096 or mail to: Department of Workers' Claims ATTN: EDI Section Prevention Park 657 Chamberlin Avenue Frankfort, KY 40601 Phone: (502) 564-5550 x4416 American LegalNet, Inc. www.FormsWorkFlow.com