Forms

Upon receipt of these forms and verification of Medicare eligibility status, a determination of the need for a set-aside arrangement will be made. If a set-aside is not required, we will confirm this in writing and no further activity will take place. If a set-aside is needed, we will send you a formal engagement letter that outlines the services this firm is to provide for your approval prior to initiating any further services. A certified nurse life care planner will complete the MSA allocation for set aside arrangements. The MSA allocation will include allowances for future medical care that Medicare would cover as well as allowances for non-Medicare eligible future medical care.

Since the claim being settled is a Liability or Workers’ Compensation claim, Medicare applies a set of criteria to any settlement on a case-by-case basis in order to determine whether Medicare has a future obligation for services that were originally the responsibility of the workers’ compensation payer. We look forward to working with you.

Worker’s Compensation Claim Forms

You can submit the Online Intake Form or, if you prefer to manually complete the Intake Form, please use the Word version of the Intake Form. The following forms may be emailed, faxed, or mailed, along with the necessary medical and pharmacy records.

SSA Release Consent to ReleaseProof of Representation Agreement

Liability Claim Forms

You can submit the Online Intake Form or, if you prefer to manually complete the Intake Form, please use the Word version of the Intake Form. The following forms may be emailed, faxed, or mailed, along with the necessary medical and pharmacy records.

SSA ReleaseConsent to ReleaseProof of Representation Agreement