MSP Compliance

Referral Date:*

Name:*

Address:*

Date of Injury:*

Date of Birth:*

SSN:*

Claim Number:*

Occupation:*

Employer:*

Specific Accepted Injuries:*

Jurisdiction:*

TYPE OF CLAIM – PLEASE CHECK ONE

Untitled*

Client:*

Referred By:*

Client Phone Number*

Client Email Address*

Defense Attorney:

Defense Attorney Phone Number

Defense Attorney Email Address

Claimant Attorney:

Claimant Attorney Phone Number

Claimant Attorney Email Address

Services Requested*

MSA Allocation Report Only (Please include 2 year Payment, Pharmacy, and Indemnity records)
CMS Legal Submission
Claim Settlement Cost Allocation (Non Threshold Criteria)
Medicare Conditional Payment Lien Research (Please include the FROI and Compensable Body Parts)
Medicare Conditional Payment Lien Negotiations (Please include the FROI and Compensable Body Parts)
Prospective (Pre) MSA Review
Drug Utilization Review
Post Settlement Professional Fund Administration

Documents Requested*

First Report of Injury/Accident
AccidentMedical Records for the past 2 years including IME, Diagnostic, Operating Notes, Treatment Summaries, etc
Payment Records for the past 2 years including Pharmacy with specific medications
Legal and Settlement Documents

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