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
Medicare Eligibility Form - PDF
Proof of Representation - Word
Annual Accounting to CMS for Structured MSAs - PDF / Word
Annual Accounting to CMS for Lump Sum MSAs - 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
Proof of Representation - Word
Annual Accounting to CMS for Lump Sum MSAs for Liability Claims - PDF / Word
Annual Accounting for Structured Annuity Liability Claims - PDF / Word
Medication Medical Provider Questionnaire (MPQ) - Word
Self Administration Structured MSA - PDF / Word
Self Administration Lump Sum MSA - PDF / Word
Self Administration of Liability - PDF / Word
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.