Overview

Medicare Referral Form

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 by email at medcompliance@dmclaw.com.

* required fields

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

Plantiff Firm: Claimant Attorney: Address: City: State: Zip: Phone: Fax: Email *:

Upon pressing the Submit Form button below, a copy of this page will be sent to the email address provided in the above text box.

Referral Type

Referral Type:

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