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Medicare Eligibility Inquiry 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 (Adobe Reader v8 or higher is required to save the completed manual referral form).


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


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* indicates a required field

Insurer Information

This should be the insurer name not the TPA's name.
Request cannot be processed until this information is received.

Claim Information
Insurance Type Selection

Key Contact and Billing Information

Please identify the referring party and any parties we should send copies of the allocation report to:

Party responsible for bill:

General File Information
Submission Details

Please include your contact information as the person submitting this form.

Notes/Special Handling

We will notify you of any required documentation and/or releases upon receipt and review of the file.