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 information for can be filled out with unknown. For print, please use the Manual Referral Form - Click Here

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)

Defendant/Insured:

Med Reserve Amount:

SETTLEMENT/MANAGEMENT SERVICE SELECTION: (Please Select Only One)

SETTLEMENT PRESCRIPTION FORECAST
A Drug Review Only for Settlement Purposes

DRUG MANAGEMENT TOOL
A Drug Review and Case Management Plan for Active Cases

SETTLEMENT CARE PLAN
A Comprehensive Medical Review for Settlement Purposes

KEY CONTACT & BILLING INFORMATION:

Referring Party
Adjuster First Name:		Adjuster Last Name:
Email Address:		Tel. Number & Extn.:
Insurance Carrier/TPA:
Address:

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

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


Structured Settlement Broker First Name:		Structured Settlement Broker Last Name:
Tel. Number & Extn.:
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):

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

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

A. Injury Report, Initial Treatment Records, and any Pre-existing/Prior Medicals.
B. 2 years of Claims Payment History.
C. 2-3 years of Medical Records.
D. 5 years of Medication Listings.
E. Any IME, AME, QME, Comprehensive Consults/Evaluations, Hospital Discharge Summaries, Awards, Court Stipulations, etc.

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.

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.