<h3 class="heading3">YOUR INFORMATION</h3>

[text* your-name class:suba placeholder "FULL NAME"]

[text your-firm class:suba placeholder "FIRM"]

[text your-address class:suba placeholder "MAILING ADDRESS"]

[text your-city class:suba placeholder "CITY"]


[select your-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]


[number your-zip min:5 class:sub placeholder "ZIP CODE"]

[email your-email class:suba placeholder "EMAIL ADDRESS"]

[number* your-phone class:digits placeholder "PHONE NUMBER"]

[number your-fax class:suba placeholder "FAX NUMBER"]

<p>I am The: </p>

[select Iamthe class:suba "-- Select --" "Claimant's Attorney" "Adjuster" "Defense Attorney"]


<h3 class="heading3">PLAINTIFF</h3>


[text* plaintiff-name class:suba placeholder "PLAINTIFF NAME"]

<p>Gender: </p>
[select gender class:suba "Male" "Female"]



[text plaintiff-file class:suba placeholder "CLAIM FILE NUMBER"]

[text plaintiff-add class:suba placeholder "PLAINTIFF ADDRESSS"]

[text plaintiff-city class:suba placeholder "PLAINTIFF CITY"]


[select plaintiff-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]


[number plaintiff-zip min:5 class:sub placeholder "PLAINTIFF ZIP CODE"]

[date d-ob class:suba placeholder "DATE OF BIRTH"]

[number plaintiff-phone class:digits placeholder "PLAINTIFF PHONE NUMBER"]


[text social-sn class:digits placeholder "SOCIAL SECURITY NUMBER"]
[date date-in class:suba placeholder "DATE OF INJURY"]

[text state-oj class:suba placeholder "STATE OF JURISDICTION"]
[text date-medi class:suba placeholder "DATE OF MEDICARE ELIGIBILITY"]
[checkbox SSDIBeneficiary use_label_element "SSDI Beneficiary"]
[date date-medication class:suba placeholder "DATE OF MEDICATION IF SET"]

[text settlement-agreement class:suba placeholder "SETTLEMENT AGREEMENT: $"]
[checkbox underlaying use_label_element "Underlying worker's compensation claims are involved."]

[textarea list-body class:suba placeholder "I1: Please list body parts and/or medical conditions to be included in the MSA."]

[textarea list-body2 class:suba placeholder "I2: Please list body parts and/or medical conditions that are NOT to be included in the MSA."]

[textarea list-body3 class:suba placeholder "Brief description of injury (example: slipped and fell, rear-ended in auto accident, etc.):"]

[checkbox GuardianAppointed use_label_element "Guardian Appointed"]
[textarea Othercomments class:suba placeholder "Other comments"]

<h3 class="heading3">PLAINTIFF ATTORNEY</h3>
[text pa-name class:suba placeholder "PLAINTIFF ATTORNEY NAME"]
[text pa-firm class:suba placeholder "PLAINTIFF ATTORNEY FIRM"]
[text pa-add class:suba placeholder "PLAINTIFF ATTORNEY ADDRESS"]
[text pa-city class:suba placeholder "PLAINTIFF ATTORNEY CITY"]

[select pa-satate class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number pa-zip min:5 class:sub placeholder "PLAINTIFF ATTORNEY ZIP CODE"]
[email pa-email class:suba placeholder "PLAINTIFF  EMAIL ADDRESS"]
[number pa-phone class:digits placeholder "PLAINTIFF PHONE NUMBER"]
[number pa-fax class:suba placeholder "FAX NUMBER"]

<h3 class="heading3">ADJUSTOR</h3>
[text adjustor-name class:suba placeholder "ADJUSTOR NAME"]
[text adjustor-firm class:suba placeholder "ADJUSTOR FIRM"]
[text adjustor-add class:suba placeholder "ADJUSTOR ADDRESSS"]
[text adjustor-city class:suba placeholder "ADJUSTOR CITY"]
[select adjustor-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]

[number adjustor-zip min:5 class:sub placeholder "ADJUSTOR ZIP CODE"]
[email adjustor-email class:suba placeholder "ADJUSTOR EMAIL ADDRESS"]
[number adjustor-phone class:digits placeholder "ADJUSTOR PHONE NUMBER"]
[number adjustor-fax class:suba placeholder "ADJUSTOR FAX NUMBER"]

<h3 class="heading3">DEFENSE ATTORNEY</h3>

[text deffenseattorney-name class:suba placeholder "DEFENSE ATTORNEY NAME"]
[text deffenseattorney-firm class:suba placeholder "DEFENSE ATTORNEY FIRM"]
[text deffenseattorney-address class:suba placeholder "DEFENSE ATTORNEY ADDRESS"]
[text deffenseattorney-city class:suba placeholder "DEFENSE ATTORNEY CITY"]

[select deffenseattorney-state class:suba  "SELECT STATE" "ALABAMA	" "ALASKA	" "ARIZONA	" "ARKANSAS	" "CALIFORNIA	" "COLORADO	" "CONNECTICUT" "DELAWARE" "FLORIDA	" "GEORGIA	" "HAWAII	" "IDAHO	" "ILLINOIS	" "INDIANA	" "IOWA	" "KANSAS	" "KENTUCKY	" "LOUISIANA	" "MAINE" "MARYLAND	" "MASSACHUSETTS	" "MICHIGAN	" "MINNESOTA	" "MISSISSIPPI	" "MISSOURI	" "MONTANA	" "NEBRASKA	" "NEVADA	" "NEW HAMPSHIRE	" "NEW JERSEY	" "NEW MEXICO	" "NEW YORK	" "NORTH CAROLINA	" "NORTH DAKOTA	" "OHIO	" "OKLAHOMA	" "OREGON	OR" "PENNSYLVANIA	" "RHODE ISLAND" "SOUTH CAROLINA	" "SOUTH DAKOTA	" "TENNESSEE	" "TEXAS	" "UTAH	" "VERMONT	" "VIRGINIA	" "WASHINGTON	" "WEST VIRGINIA	" "WISCONSIN	" "WYOMING"]
[number deffenseattorney-zip min:5 class:sub placeholder "DEFENSE ATTORNEY ZIP CODE"]
[email deffenseattorney-email class:suba placeholder "DEFENSE ATTORNEY EMAIL ADDRESS"]
[number deffenseattorney-phone class:digits placeholder "DEFENSE ATTORNEY PHONE NUMBER"]
[number deffenseattorney-fax class:suba placeholder "DEFENSE ATTORNEY FAX NUMBER"]

<h3 class="heading3">AVAILABLE SERVICES</h3>
<p>*Please check appropriate box(s) below for the requested services.  <br>

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.</p>

[checkbox checkbox-496 class:suba "Determine Medicare Status: Includes verification thru SSA inquiry of Insured's SSDI/Medicare status and legal opinion regarding whether or not MSA is recommended. Plaintiff's signed SSA release required.."]

[checkbox checkbox-497 class:suba "Calculate MSA Allocation: Includes medical treatment chronology; future medical cost and drug cost tables based on rated age life expectancy; structured annuity quote.."]

[checkbox checkbox-498 class:suba "Medical Cost Projection: For valuing claim and setting reserves. No MSA analysis. Release forms not required. Option to convert to MSA available.."]

[checkbox checkbox-499 class:suba "Expedited Service: Completion of MSA Allocation within 5 business days of receipt of the necessary records (additional fee applies).."]


[checkbox checkbox-500 class:suba "Revision of MSA: Includes review of medical and pharmacy records since the most recent records provided for original MSA; updated tables based on current pricing and life expectancy; new rated age if appropriate.."]

[checkbox checkbox-501 class:suba " Recovery Claim Search: Medicare Recovery Claim Research: Includes inquiries to CMS to obtain conditional payment information; requires Plaintiff's signed consent; does not include legal argument for compromise / waiver.."]

[checkbox checkbox-502 class:suba "Submit to CMS: Submit to CMS for approval of Medicare Set- Aside arrangement; Plaintiff's signed consent required.."]

[checkbox checkbox-503 class:suba "Complete MSA Bundle: Includes verification of Plaintiff's SSDI and Medicare status; competion of MSA Allocation; conditional payment research; submission of MSA to CMS if desired.."]

[checkbox checkbox-504 class:suba "Compromise of Medicare's Conditional Payment: Includes legal argument to support request for reduction or waiver of CMS conditional payment recovery claim; Plaintiff's signed consent required.."]

[checkbox checkbox-506 class:suba "Onsite Copy/Scanning: Copy requests should be submitted 24 hours in advance of the appointment day to allow us time to coordinate your service request."]



[submit class:btn-submit "SUBMIT"]
1
Manley & Associates "Liability Intake" Form Submission
[your-name] <wordpress@manleyandassociates.com>
lawatson@bmanleymsa.com, nformisano@bmanleymsa.com, msareferrals@manleyandassociates.com, atimms@manleyandassociates.com
From: [your-name] <[your-email]>

FORM TYPE: Liability Intake

<h3 class="heading3">YOUR INFORMATION</h3>

YOUR NAME:
[your-name]

YOUR FIRM:
[your-firm]

YOUR ADDRESS:
[your-address]

YOUR CITY:
[your-city]

YOUR STATE:
[your-state]

YOUR ZIP:
[your-zip]

YOUR EMAIL:
[your-email]

YOUR PHONE:
[your-phone]

YOUR FAX:
[your-fax]

I AM THE:
[Iamthe]


<h3 class="heading3">PLAINTIFF</h3>

PLAINTIFF NAME:
[plaintiff-name]

GENDER:
[gender]

CLAIM FILE NUMBER:
[plaintiff-file]

PLAINTIFF ADDRESS:
[plaintiff-add]

PLAINTIFF CITY:
[plaintiff-city]

PLAINTIFF STATE:
[plaintiff-state]

PLAINTIFF ZIP:
[plaintiff-zip]

DATE OF BIRTH:
[d-ob]

PLAINTIFF PHONE NUMBER:
[plaintiff-phone]

DATE OF INJURY
[date-in]

STATE OF JURISDICTION
[state-oj]

DATE OF MEDICARE ELIGIBILITY:
[date-medi]

SSDI Beneficiary:
[SSDIBeneficiary]

DATE OF MEDICATION (IF SET):
[date-medication]

SETTLEMENT AGREEMENT: $
[settlement-agreement]

Underlying worker's compensation claims are involved.:
[underlaying]

I1: Please list body parts and/or medical conditions to be included in the MSA. :
[list-body]

I2: Please list body parts and/or medical conditions that are NOT to be included in the MSA. :
[list-body2]

Brief description of injury (example: slipped and fell, rear-ended in auto accident, etc.):
[list-body3]

Guardian Appointed:
[GuardianAppointed]

Other comments:
[Othercomments]


<h3 class="heading3">PLAINTIFF ATTORNEY</h3>

PLAINTIFF ATTORNEY NAME:
[pa-name]

PLAINTIFF ATTORNEY FIRM:
[pa-firm]

PLAINTIFF ATTORNEY ADDRESS:
[pa-add]

PLAINTIFF ATTORNEY CITY:
[pa-city]

PLAINTIFF ATTORNEY STATE:
[pa-satate]

PLAINTIFF ATTORNEY ZIP:
[pa-zip]

PLAINTIFF ATTORNEY EMAIL:
[pa-email]

PLAINTIFF ATTORNEY PHONE:
[pa-phone]

PLAINTIFF ATTORNEY FAX:
[pa-fax]


<h3 class="heading3">ADJUSTOR</h3>

ADJUSTOR NAME:
[adjustor-name]

ADJUSTOR FIRM:
[adjustor-firm]

ADJUSTOR ADDRESS:
[adjustor-add]

ADJUSTOR CITY:
[adjustor-city]

ADJUSTOR STATE:
[adjustor-state]

ADJUSTOR ZIP:
[adjustor-zip]

ADJUSTOR EMAIL:
[adjustor-email]

ADJUSTOR PHONE:
[adjustor-phone]

ADJUSTOR FAX:
[adjustor-fax]


<h3 class="heading3">DEFENSE ATTORNEY</h3>
DEFENSE ATTORNEY NAME:
[deffenseattorney-name]

DEFENSE ATTORNEY FIRM:
[deffenseattorney-firm]

DEFENSE ATTORNEY ADDRESS:
[deffenseattorney-address]

DEFENSE ATTORNEY CITY:
[deffenseattorney-city]

DEFENSE ATTORNEY STATE:
[deffenseattorney-state]

DEFENSE ATTORNEY ZIP:
[deffenseattorney-zip]

DEFENSE ATTORNEY EMAIL:
[deffenseattorney-email]

DEFENSE ATTORNEY PHONE:
[deffenseattorney-phone]

DEFENSE ATTORNEY FAX:
[deffenseattorney-fax]


<h3 class="heading3">AVAILABLE SERVICES</h3>

[checkbox-496]
[checkbox-497]
[checkbox-498]
[checkbox-499]
[checkbox-500]
[checkbox-501]
[checkbox-502]
[checkbox-503]
[checkbox-504]
[checkbox-506]

--
This e-mail was sent from a contact form on Manley &a Associates (https://manleyandassociates.com)


1


Manly & Associate "[your-subject]"
Manly & Associate <wordpress@demo.likeconception.com>
[your-email]
Message Body:
[your-message]

--
This e-mail was sent from a contact form on Manly &amp; Associate (http://demo.likeconception.com/like)
Reply-To: likeconceptioninfo@gmail.com



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