Workers Compensation Benefits and Medicare Services

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 info 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 to please call (866) 672-3453 (MSA-FILE).

CASE INFORMATION:

Claimant/Plantiff
First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Social Security Number:

Claim Number:

Date of Birth:
(mm-dd-yyyy)

Date of Injury:
(mm-dd-yyyy)

Defendant/Insured:

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

MSA Allocation LIMITED
Examples: fracture clavicle healed; back strain (no surgery) pain resolved and not currently treating; extr emity 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

ADDITIONAL SERVICES

Lien Research

Lien Negotiations

Medicare/Social Security Status Verification

Prescription Drug Review (PDR)

KEY CONTACT & BILLING INFORMATION:

Referring Party
Adjuster Name:		Tel. Number & Extn.:
Email Address:		Fax:
Insurance Carrier/TPA/ Servicing Agent:
Address:

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

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

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

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

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

Party Responsible for Bill Insurance Carrier/TPA/Servicing Agent 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 or is the claimant a Medicare Beneficiary? (If yes, please provide supporting documentation.)	YES	NO	Not Known
2. May we contact the plaintiff counsel/claimant? (No contact will be made to plaintiff counsel, claimant, COB, SSA or any medical providers without signed releases. If left unmarked, we will presume “NO”.)	YES	NO	Not Known
3. Are there any negligence issues? If yes, please detail in questionnaire below.	YES	NO	Not Known
4. Has a proposed settlement been reached? If yes, what is the total amount?	YES	NO	$
5. Has a rated age been obtained? If yes, indicate settlement broker above.	YES	NO	Not Known
6. Are there any underlying workers’ comp claims involved?	YES	NO	Not Known
7. Do you want us to contact Medicare to determine if liens exist? (If so, please state information about this on the Negligence Issues Client Questionnaire (below) and release must be received.).	YES	NO	Not Known
8. What are the policy limits?
9. Who will be handling your CMS submission?	Gould & Lamb	Specialized Legal Councel	Other

Notes/Special Handling:
(Please list any deadlines, pre-trial dates, mediation/court dates) Please complete attached questionnaire.

RSM/AAM Email Address
(Internal Use Only)

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. If we do not receive information needed, G&L will get the information for you. G&L reserves the right to change service selection based on injury type and volume of records upon review and notification to referring party.

NEGLIGENCE ISSUES CLIENT QUESTIONNAIRE

This referral was identified as having possible negligence issues. Additional clarification is required in order to facilitate an accurate analysis of the case and completion of the Medicare Set-Aside Allocation. Please complete the attached questionnaire within 48 hours of receipt and reply via email to the sender or by facsimile at 941-798-3403.

If this questionnaire is not returned within 48 hours, the allocation report will be compiled with the available information provided in the initial submission, which may or may not support the negligence position. Additional costs will be incurred if the information listed below is reviewed after the allocation report has been completed.

1. May we contact defense counsel on this claim?	YES	NO
2. Has the entire claim been disputed based upon a “no liability defense”?	YES	NO
3. Have you accepted liability for all alleged body parts connected to the accident? If not, list body parts that you are controverting?	YES	NO
4. Are monies included in the settlement for future medical care?	YES	NO
5. Have any medical payments been made for disputed services/treatment?	YES	NO
6. What date was the case first disputed?	(MM/DD/YYYY)
Please explain the specific condition or care that is being disputed. Include all legal and medical reasons as well as supporting documents/records to support basis for denial of liability.
Please list any prior injuries that pre-date this claim:
Is the claimant currently treating? List treating physician, address and phone number:
What do you expect the allocation to provide? Please mark only one. Zero Dollar Allocation Only Estimated Future Medical Expenses without a Zero Dollar Allocation Zero Dollar Allocation with Estimated Future Medical Expenses

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.