Your Information

Prefix

First Name

Mid Name

Last Name

Suffix

Your Firm Name

Street

City

State

Zip

Your Email Address

Phone

Fax

And You Are The: Plaintiff's Attorney: Adjuster: Defense Attorney:

Plaintiff

Prefix

First Name

Mid Name

Last Name

Suffix

Sex Male: Female:

Claim File No

Street

City

State

Zip

Date Of Birth

Phone

Social Security Number

E-mail

State of Jurisdiction

Date Medicare Eligible?

SSDI Beneficiary

Mediation Date

Settlement Agreement $

Underlying workers' compensation claims are involved

Comparable negligence or apportionment of injuries found

Settlement includes funds for future medical care

Claim has been disputed based upon a "no liability" defense

Date Claim first disputed

Explain specific condition or care that is being disputed. Include all legal & medical reasons as well as supporting documents/records to support dinal of claim

Keep Brief

Body parts injured (e.g. neck, back) (no carriage returns please)

Keep Brief

Structured Settlement Broker (if utilized)

Guardian Appointed

Administrator

Phone

Other Comments (no carriage returns please)

Plaintiff Attorney

Prefix

First Name

Mid Name

Last Name

Suffix

Firm Name

Street

City

State

Zip

Email Address

Phone

Fax

Adjustor

Prefix

First Name

Mid Name

Last Name

Suffix

Firm Name

Street

City

State

Zip

Email Address

Phone

Fax

Defense Attorney

Prefix

First Name

Mid Name

Last Name

Suffix

Firm Name

Street

City

State

Zip

Email Address

Phone

Fax

Available Services

Fees for services are due upon completion of the assignment. An invoice will be sent with the final report. Note that there may be an additional charge by the treating provider for completion of our questionnaire. If your case proves unusually complex and requires large expenditures of time beyond what is customary and reasonable, there may be additional charge. We will communicate with you prior to making this charge.

Make determination if set-aside arrangement is necessary by verifying insured's SSDI and Medicare status. Complete SSA 3288 form.
Determine Medicare Status

Calculate MSA Allocation for future medical care with settlement language. Includes rated age & annuity purchase quote.
Calculate MSA Allocation

Expedited Service (5 day RUSH) for completion of MSA
Rush

Revision of MSA allocation
Revision

Recovery Claim Search / Notice: No legal argument for compromise / waiver. Complete Representative Release Form
Recovery Claim Search

Submit to CMS for approval of Medicare set aside arrangement
Submit to CMS

Includes legal opinion of necessity of MSA, conditional payment research/notice, completion of MSA, and submission to CMS
Complete MSA Bundle

Other Services

For valuing claim and setting reserves. No MSA analysis.
Medical Cost Projection

Request MSPRC removal of inappropriate claims. Complete Representative Release Form.
Compromise Or Waiver Of Medicare's Conditional Payment

Onsite Copy Service Please click here for more information. (Will open new window.)