Medicare Set-Aside Referral Form We will contact you within one Business day. All information provided is held in confidence. ( * Required fields ) Today's Date Services Requested Obtain signed releases Verification of SSD/Medicare Status (requires signed releases) Medical Lien Verification (applicable only if patient has Medicare benefits) Obtain rated age (requires records not more than 3 years old) Medicare Set Aside Allocation (see document requirements) Submission of MSA to CMS (see document requirements) Rush Completion (additional charge) Details of the Requesting Party Name* Phone* Extension Fax Contact Email Details of Billing Bill To* Address 1* Address2 City* State* Zip Details of the Injured Individual WC Claim Number Patient's Social Security Number* Patient's Last Name* Patient's First Name* Patient's Gender Male Female HICN* Address 1 Address2 City State Zip Phone Number Date of Birth* Date of Injury Diagnosis Related Diagnosis Unrelated / Denied Details of the Patient's Employer Company Contact Phone Number Fax Number Address City State Zip Details of the Patient's Plaintiff Attorney Name * Phone Number * Fax Number * Email Address City State Zip Details of the Patient's Defense Attorney Name * Phone Number * Fax Number * Email Address City State Zip Any Additional Comments Enter Verification Code

   Documents Required:

· Medicare Set Aside Allocation Comprehensive report will include: costs for Medicare-covered services related to the covered injury/illness; projected future medical care including injury / illness related medications; non-covered services (pre-existing/unrelated medical conditions, unrelated medications, including exhausted benefits), recommended Medicare Set-Aside Allocation amount. Provide the following documents: · Notice of Loss · Medical records; initial 6 months of treatment for last 2 years · Medications' profile for last two years (per CMS) · Physician Statement regarding Life Expectancy (if available) · Payment history for the last 2 years to include medication listing (per CMS) If available please provide: · Signed Social Security Administration release of information (SSA-3288) If requesting Entitlement verification · Signed CMS release (Medicare's Consent to Releases form) · Life Care Plan/Medical Projection if available · Rated age (company letterhead) or independent Broker's statement of rated age quote(s) · Identify whether trust will be self-administered or professionally administered · Structure/Trust Settlement information (company letterhead) · Legal document(s) that identify relatedness or denial of specific treatment (Jurisdictional Limitations) · Submission of Medicare Set-Aside to Center for Medicare/Medicaid Services (CMS) Submit completed MSA with required attachment to CMS: · Signed Medicare release of information (CMS release form) · Signed VP Medical Consulting release of information · Structure/Trust Settlement information (on company letterhead) if applicable · Draft or Final Settlement Agreement (C/R Agreement)