X12 Home Store Members Contact Us IP Use ASC X12 Work Request Form Work Request Form(After completing the form, hit the Submit button at the bottom of the screen.) A. Submitter Information Submitter Name: Company: Address 1: Address 2: City: State: Zip + 4: Country: Phone: E-mail: Submission represents the position of: B. Reference Used: Version: Release: Subrelease: or Workbook (Date: MM/DD/YYYY): C. Intended Use: Transaction Set(s): Segment(s): Composite Data Element(s): Data Element(s): Code Source(s): Other: CICA Construct: (Note: If creating a new CICA Document, what is the existing template upon which the new document is based? D. Business Case/Reason For Change: E. Proposed Work: Work Request Form Part TwoForm for New or Revised External Code Source Reference for X12.3 Data Element Dictionary Instructions: Complete this form only when a new data element or data element code reference is requested to be added to Appendix A of X12.3 Data Element Dictionary which references a code list published by an organization external to X12. Use one form for each new or revised reference. This form may be used to revise current references; fill out the appropriate areas below. Part 1: Reference Check 1 or 2 below. If 2, fill in the current reference number. 1. New Reference 2. Revised Reference, current reference number/name Part 2: Reference Title If there is only one source for codes for the data element, the title should be the same as the data element name. If there are multiple codes referencing external code sources for the same data element, title should approximate the code definition. Reference Title: Part 3: Data Elements Used In Give the data element reference number and name which directs the user to this code source. Give the code ID (if assigned) if this is for a specific code of the data element. Used In: DE No. Code ID Part 4: Source Provide the name of the publication which contains the codes referenced. Published In: Part 5: Available FromGive the publisher or other contact from whom the user can obtain the document. Name/Attn. of Company Address City State Zip + 4 Country Alternate Phone Number Part 6: URL (If available) Part 7: AbstractBriefly describe the publication, its purpose, and indicate what codes it contains.