Refer A Medicare Set-Aside | MSA Referral Form

Natalie Clark
3565 Piedmont Road NE
Building 1, Suite 525
Atlanta, GA 30305
Office: 404-926-4160 x215
Fax: 404-926-4161
Email: Natalie Clark
View Natalie’s Bio

Please find below our referral form for both workers’ compensation and liability Medicare claims, including all Longshore and Jones Act matters. Please provide the requested information so that a team member may reach out to you regarding your inquiry and advise as to the information needed to assist you. We look forward to assisting you in meeting your Medicare compliance objectives.

(* indicates required fields)

Claim Type: *
Referral: * Medicare/SSD EligibilityMedicare Set-Aside ReportConditional Payment Inquiry

Referring Contact Information:

State:

Claimant Information:

State:

Date of Birth:
Social Security Number:
Date of Injury:

State of Injury/Venue *:

Claimant's Counsel:

Plaintiff's Counsel:

Additional Information:
MMI:
Total 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?
What is the approximate Settlement Value? $
Is the Claimant Receiving SSD Benefits?
Is the Claimant Medicare Eligible?

Attach a File: (Size limit: 5mb | File types: jpg, png, gif, pdf, doc, docx)

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Refer A Medicare Set-Aside | MSA Referral Form

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