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 we are 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 form or, if you prefer to manually complete the Intake Form, please use the downloadable printable version. The following forms may be emailed, faxed, or mailed, along with the necessary medical and pharmacy records.

SSA RELEASE
CONSENT TO RELEASE
PROOF OF REPRESENTATION AGREEMENT


LIABILITY CLAIM FORMS

You can submit the online form or, if you prefer to manually complete, please use the downloadable form. The following forms may be emailed, faxed, or mailed, along with the necessary medical and pharmacy records.

SSA RELEASE
CONSENT TO RELEASE
PROOF OF REPRESENTATION AGREEMENT


OTHER FORM DOWNLOADS

PROOF OF REPRESENTATION (This Proof of Representation Agent Agreement must be printed on the Insurer's letterhead.)

BENEFICIARY PROOF OF REPRESENTATION

ANNUAL ACCOUNTING TO CMS FOR STRUCTURED MSAs FORM 

ANNUAL ACCOUNTING TO CMS FOR LUMP SUM MSAs FORM