Medicare Referral Form

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.

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Claimant Information

Settlement Information

Injury Information

Insurer/Carrier Information

Attorney Information

Referral Type