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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

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)