Medicare Set-Aside Referral Form

Requested Information
   

Claimant Information

   Claimant Name:
   Address:
   City:
   State:
   Zip:
   Phone:
   Date of Birth:
   

Settlement Information

   Proposed Settlement Date:
   Proposed Settlement Amount:
   Professional or Self
   Admin. of MSA:
   

Injury Information

   Claim #:
   Date of Injury:
   Compensable Body Part(s):
   Denied Body Part(s):
   Jurisdiction:
   ICD-9 Codes:
   Case Type (WC, Liab.):
   

Insurer/Carrier Information

   Company Name:
   Contact:
   Address:
   City:
   State:
   Zip:
   Phone:
   Fax:
   Email:
   

Attorney Information

   Plaintiff Firm:
   Claimant Attorney:
   Address:
   City:
   State:
   Zip:
   Phone:
   Fax:
   Email:
   

Referral Type

Please print a copy of this form for your records before submitting.

 

Upon submission of a file referral, a DMC Medicare Compliance team member will contact you to confirm receipt of your assignment. If you have any questions, please contact Benjamin M. Basista at 412-392-5493 or W. Brian Rambin at 412-392-5564 or by email at medcompliance@dmclaw.com.