DOWNLOADABLE FORMS
WORKERS COMPENSATION CLAIM FORMS
MSA Intake Form - PDF / Word / On-Line
Social Security Release Form 3288 - PDF / Word
MSA Representative Release/Consent Form - PDF / Word
MSA Representative Release/Consent Form Unrepresented - PDF / Word
LIABILITY CLAIM FORMS
MSA Intake Form - PDF / Word / On-Line
Social Security Release Form 3288 - PDF / Word
MSA Representative Release/Consent Form - PDF / Word
MSA Representative Release/Consent Form Unrepresented - PDF / Word
Annual Accounting to CMS for Structured MSAs - PDF
Terms and Conditions - Administering Your Lump Sum Workers' Compensation
Medicare Set-Aside Arrangement (MSA) - PDF
Annual Accounting to CMS for Lump Sum MSAs - PDF
Terms and Conditons - PDF / Word
You can also fill out the Online Intake form located
here. Upon receipt of these forms and verification of Medicare eligibility status, a determination of the need for a set-aside arrangement will also be made. If a set-aside is not required, we will confirm this in writing and no further activity will take place. If a set-aside is needed, we will send you a formal engagement letter that outlines the services this firm is to provide for your approval prior to initiating any further services. A certified nurse life care planner will complete the MSA allocation for set aside arrangements. The MSA allocation will include allowances for future medical care that Medicare would cover as well as allowances for non-Medicare eligible future medical care.
Since the claim being settled is a Liability or Workers' Compensation claim, Medicare applies a set of criteria to any settlement on a case-by-case basis in order to determine whether Medicare has a future obligation for services that were originally the responsibility of the workers' compensation payer. We look forward to working with you.