Workers Compensation Benefits and Medicare Services

Gould & Lamb Homepage

A Medical-Financial Services Company
101 Riverfront Blvd. Suite 100
Bradenton, FL 34205
Tel: (941) 798-2098
Fax: (941) 798-3403
Email: clientservices@gouldandlamb.com

Home > Medicare Set-Aside Arrangement > Online Referral Form

WORKERS' COMPENSATION

Medicare Set-Aside Arrangement Online Referral Form

PLEASE DO NOT PRINT THIS FORM.

Fill in the required details and hit submit at the bottom of the page. Any fields that you do not have relevant information for can be filled out with “unknown”. For print, please use the Manual Referral Form - click here

If this is your first time filling out our referral form and you would like assistance please call 866-672-3453 (MSA-FILE).

CASE INFORMATION:

Claimant First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Social Security #:

Claim Number:

Date of Birth:
(mm-dd-yyyy)

Date of Injury:
(mm-dd-yyyy)

Employer:

WC Jurisdiction:

MSA SERVICE SELECTION: (Select one service only - call if uncertain. *The Prescription Drug Review may be selected with a MSA Allocation)

MSA Allocation LIMITED
Examples: fracture clavicle healed; back strain (no surgery) pain resolved and not currently treating; extremity fractures without complications

MSA Allocation STANDARD
Examples: herniated disc injury; multiple trauma with healed fractures; chronic pain (no DCS or Morphine Pumps); stabilized knee injuries; carpal tunnel
syndrome

MSA Allocation COMPLEX
Examples: traumatic brain injuries; paraplegia; quadriplegia; amputees; toxic exposure cases; complex RSD requiring DCS/Morphine pumps; major depression with psychiatric hospitalization

CAP Service
Contact your regional account manager for details about the G&L CMS Assurance Program or call 1-866-672-3453.

ADDITIONAL SERVICES

Lien Research

Lien Negotiations

Medicare/Social Security Status Verification

Prescription Drug Review (PDR)

KEY CONTACT & BILLING INFORMATION:

Referring Party
Adjuster First Name:		Adjuster Last Name:
Email Address:		Tel. Number & Extn.:
Insurance Carrier/TPA:		Fax Number:
Address:
NOTE: TPAs/Insurers servicing another carrier's claims, please list carrier here:

Referring Party
Other Contact First Name:		Other Contact Last Name:
Email Address:		Tel. Number & Extn.:
Company Name :		Fax Number:
Address:

Referring Party
Defense Attorney First Name:		Defense Attorney Last Name:
Tel. Number & Extn.:		Fax Number:
Address:
Defense Firm Name:
Email Address:

Referring Party
Plaintiff Attorney First Name:		Plaintiff Attorney Last Name:
Tel. Number & Extn.:		Fax Number:
Address:
Plaintiff Firm Name:
Email Address:

Referring Party
Structured Settlement Broker First Name:		Structured Settlement Broker Last Name:
Tel. Number & Extn.:		Fax Number:
Email Address :

Please provide copies of the allocation report to: Carrier/TPA Defense Attorney Plaintiff Attorney Structure Broker Other

Party Responsible for Bill Insurance Carrier/TPA Referring Party
Billing Address & Tel. # (if different from above):

FILE INFORMATION:

1. Has the claimant applied, denied and/or appealing; or receiving Social Security Disability payments? (If yes, please provide supporting documentation.)	YES	NO	Not Known
2. Is the claimant currently a Medicare beneficiary?	YES	NO	Not Known
3. Have the releases been sent to plaintiff counsel/claimant?	YES	NO	Not Known
4. Are there any controverted issues? If yes, please note below.	YES	NO	Not Known
Please fill out a little more information about your controverted issues. 1) May we contact defense counsel on this claim? YES NO 2) Has the entire claim been controverted? YES NO 3) Is only a portion of the claim controverted? YES NO 4) Are monies included in the settlement for future medical care? YES NO 5) Have any medical payments been made for controverted services? YES NO Please explain the specific condition or care that is being controverted. Include all legal & medical reasons & supporting documents/records to support basis for denial. If there are multiple claims or prior work injuries, please list which ones are controverted. If the case involves cumulative trauma, toxic exposure or occupational disease, please provide any toxicology reports, environmental studies or other documentation that substantiates or repudiates the claim. What date was the case first controverted? Is the claimant currently treating? List treating physician, address, and phone #. What type of allocation report are you requesting on this controverted file? Check One Standard MSA with Future Medical Cost Projections Zero Allocation for Future Medical Cost Projections Zero Allocation with an estimate of Future Medical Exposure
5. Has this claim been settled? If yes, what is the total amount?	YES	NO	Amount:
6. Has a rated age been obtained? If yes, note broker above.	YES	NO	Not Known
7. Who will be handling your CMS submission?	Gould & Lamb	Specialized Legal Counsel	Other
Please fill out a little more information about your claim to assist in submitting to CMS immediately post MSA completion. Liens:(Total amount of conditional payments made by Medicare) Total Amount of Attorney Fees: Total Amount of Indemnity Settlement: Select one of the following funding options: Lump Sum Annuity Select one of the following administration options: Self-Administration Custodian Custodial Name: Custodial Address:

Notes/Special Handling:
(controverted issues, deadlines, mediation/court date, etc)

RSM/AAM Email Address
(Internal Use Only)

Required Minimum Documentation.
Once the referral form is complete, print a copy and forward it along with the following documentation:

A. Last 3 years of medical records.
B. The first notice of injury along with medical records at the time of injury.
C. The original signed releases supplied by Gould & Lamb (not required at time of referral).
D. Last 2 years of medical claims payment history.
E. Last 2 years of medication and DME listing, if available. If not available, please supply us with the name of the prescription supplier (i.e., Rx Solutions, PMSI, Express Scripts) so that we may contact them.
F. Any court stipulations stating demand for compensability.
G. Any CMS or Social Security documentation.

If you have any questions please contact the Gould & Lamb Client Services Department at (866) 672-3453 (MSA-FILE) between 8:30 am and 7:00pm EST Monday through Friday.

Incomplete records or delayed receipt of the required documents may delay the processing of your file and may not serve your needs in a timely manner. We will notify you of any missing documentation upon receipt of the file. G&L reserves the right to change service selection based on injury type and volume of records upon review and notification to referring party.

Checklist
Claimant General Release Form
SS Release Form

If you have any questions please contact the Gould & Lamb Client Services Department at (866) 672-3453 (MSA-FILE) between 8:30 am and 7:00pm EST Monday through Friday.