Medicare Compliance

Overview

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.

Claimant Information


Settlement Information


Injury Information


Insurer/Carrier Information


Attorney Information


Referral Type