Referral Form
Company/Firm Referring
First Name of Person Referring
*
Last Name of Person Referring
*
Email Address of Person Referring
*
Phone Number of Person Referring
Street Address
City Or Town
State
ZIP Code
Services Requested
*
?
Medicare Set Aside analysis
Submission to CMS
Medicare Part A & B Conditional Payment Search
Medicare Advantage (Part C) Lien Search
Contest/Appeal of Conditional Payments
Future Medical Allocation - Non Submit MSA
Future Medical Cost Projection - For Demand
Social Security Offset Language
MSA Trust Language for Settlement Documents
Drafting Full and Final Stipulations/Release
Claimant/Plaintiff's Name
*
Claimant/Plaintiff's Address
Claimant/Plaintiff's Phone #
Claimant/Plaintiff's Date of Birth
Benefit Status
*
On Medicare because of age (65 or older)
On Medicare because of SSDI status
Reasonable Expectation of Medicare Enrollment
No Reasonable Expectation of Medicare Enrollment
Unknown
Please select at least one benefit status
Claimant/Plaintiff's Medicare # (HICN) and/or Social Security Number
Does Claimant have a Medicare Advantage Plan?
Yes
No
Not Sure
Please select an option
please list the name of medicare Advantage Plan
Type of Case
*
Workers' Compensation
Personal Injury/Liability
Both WC and Liability
Other
Date of Injury
*
Please provide a valid injury date
Claim Number
List All Injuries Claimed
*
?
Estimated Settlement Amount
Respondent Employer/Defendant's Name
Respondent Employer/Defendant's Address
Respondent Employer/Defendant's Phone #
Insurer Respondent's Name
Insurer Respondent's Address
Insurer Respondent's Phone #
Additional Relevant Information (Denied Body Parts etc.)
Submit
