Medicare Set-Aside Evaluation Referral Form

Claim

Select Workers Comp Liability

Referral

Medicare/SSD Eligibility

Medicare Set-Aside Report

Conditional Payment Inquiry

Referring Contact Information

		Preferred broker
Name		Mailing Address
City		State	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinios Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip		Phone
Fax		Email

Claimant Information

Claimant Name		Claim Number
Address		City
State	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinios Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip
Date of Birth		Social Security Number
Employer (if w/c) or Defendant		Date of Injury
State of Loss / Venue	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinios Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Claimant's Counsel Information

Name

Phone

Defendant's Counsel Information

Name

Phone

Additional Information

MMI	Yes No
Medicals Paid To Date $
What was the Claimant's job at the time of loss (if worker's comp)?
Is there an underlying Worker's Compensation claim (if liability)?
Please give a description of the loss causing event
What are the accepted/admitted injuries?
What injuries have been denied in the claim?
Approximate Settlement Value $

Is the Claimant Receiving SSD Benefits? Yes No	Is the Claimant Medicare Eligible? Yes No

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