Medicare Set-Aside Referral Form

Claimant Information Injury Information
Name:
Address:
City:
State:
Zip:
Phone:
Date of Birth:
* Gender: male  female
unknown
Social Security #:
SSDI Entitlement Date:
Medicare #/ HICN:
MC Entitlement Date:
Medicaid:
* Claim #:
Date of Injury:
Compensable Body Part(s):
Denied Body Part(s):
ICD-9 Codes:
Jurisdiction:
Case Type (WC, Liab.):
Referring Party Information Insurer/Carrier Information
* Name:
Job Title:
Address:
City:
State:
Zip:
* Phone:
Fax:
* Email:
Company Name:
Contact:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Attorney Information - DA Attorney Information - PA
Defense Firm:
Defense Attorney:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Plaintiff Firm:
Plaintiff Attorney:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Settlement Information * Referral Type
Proposed Settlement Date:
Proposed Settlement Amount:
Professional or Self Admin. of MSA:
Additional Instructions/Comments
The WellComp MSP Team is grateful for the opportunity to assist you in your case
Do not alter the following fields: