MSA Referral Request Form

Referral Source

Name:

Phone:
Fax:

Address:
City:
State:
Zip:

Email:

Report to be sent to:

 Carrier/TPA/Servicing Agent
Adjuster
Defense Attorney
Plaintiff Attorney
Other:
Requested Date of Completion: RUSH:
Services Requested:
Phase I (file review for determination of necessity of MSA Arrangement)
Required Documents:
First Notice of Injury
Proposed Settlement Amount
Medicare entitlement letter OR
SSA 3288 Information Release signed by beneficiary AND
CHOICE Information Release signed by beneficiary
Phase II (MSA Arrangement with cost analysis, rated age on request, lien inquiry)
Required Documents:
SSA 3288 Information Release signed by beneficiary
CHOICE Information Release signed by beneficiary
All medical records
All medical billing/claims payment printout
DME, prescription list (if not included in payment printout)
Documentation of controverts, mediation, or conference dates
Phase III (MSA Arrangement with cost analysis, for complex claims with proposed settlement of $250,000 or greater, or catastrophic injuries)
Required Documents: Phase I and Phase II
Other Services Requested:
CMS Submission(required documents: settlement proposal docs; funding and administration)
Other:
Beneficiary Information

Name:

 SSN:

DOB:

 DOI:
Claim number: Phone:

Address:

    
City:    
State:    
Zip:    

State of Jurisdiction:

    
Plaintiff Attorney

Firm Name:

 Attorney Name:

Address:

 Phone:
City: Fax:
State: Email:
Zip:    
Defense Attorney

Defense Firm Name:

Attorney Name:

Address:

Phone:
City: Fax:
State: Email:
Zip:    
Special Instructions: