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:

Social Security #:

Claim Number:

Date of Birth:
(mm-dd-yyyy)

Date of Injury:
(mm-dd-yyyy)

Defendant/Insured:

DOL Jurisdiction:

Employer Name:

Employer Address:

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; 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 Negotiation

Medicare/Social Security Status Verification

Prescription Drug Review (PDR)

KEY CONTACT & BILLING INFORMATION:

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

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

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

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

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

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? (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
5. Has this claim been settled? If yes, what is the total amount?	YES	NO
6. Has a rated age been obtained? If yes, note settlement broker above.	YES	NO	Not Known
7. Who will be handling your CMS submission?	Gould & Lamb	Specialized Legal Counsel	Other

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. All available medical records including any IME's.
B. Maximum Medical Improvement (MMI) and Percentage of Impairment (PIR) documents.
C. The first notice of injury along with medical records at the time of injury.
D. The original signed releases supplied by Gould & Lamb.
E. All available medical claims payment history.
F. If available, a medication and DME listing. 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.
G. All applications for Social Security disability,any award letter from SS, or denial letter from SS.
H. Any court stipulations stating demand for compensability.
I. 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.