Liability Intake Form

YOUR INFORMATION

SELECT STATEALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGON ORPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

I am The:

-- Select --Claimant's AttorneyAdjusterDefense Attorney

PLAINTIFF

Gender:

MaleFemale

SELECT STATEALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGON ORPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

SSDI Beneficiary

Underlying worker's compensation claims are involved.

Guardian Appointed

PLAINTIFF ATTORNEY

SELECT STATEALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGON ORPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

ADJUSTOR

SELECT STATEALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGON ORPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

DEFENSE ATTORNEY

SELECT STATEALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGON ORPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

AVAILABLE SERVICES

*Please check appropriate box(s) below for the requested services.

Fees for services are due upon completion of the assignment. An invoice will be sent with the final report. Note that there may be an additional charge by the treating provider for completion of our questionnaire. If your case proves unusually complex and requires large expenditures of time beyond what is customary and reasonable, there may be additional charge. We will communicate with you prior to making this charge.

Determine Medicare Status: Includes verification thru SSA inquiry of Insured's SSDI/Medicare status and legal opinion regarding whether or not MSA is recommended. Plaintiff's signed SSA release required..

Calculate MSA Allocation: Includes medical treatment chronology; future medical cost and drug cost tables based on rated age life expectancy; table of non-Medicare covered medical services; structured annuity quote..

Medical Cost Projection: For valuing claim and setting reserves. No MSA analysis. Release forms not required. Option to convert to MSA available..

Expedited Service: Completion of MSA Allocation within 5 business days of receipt of the necessary records (additional fee applies)..

Revision of MSA: Includes review of medical and pharmacy records since the most recent records provided for original MSA; updated tables based on current pricing and life expectancy; new rated age if appropriate..

Recovery Claim Search: Medicare Recovery Claim Research: Includes inquiries to CMS to obtain conditional payment information; requires Plaintiff's signed consent; does not include legal argument for compromise / waiver..

Submit to CMS: Submit to CMS for approval of Medicare Set- Aside arrangement; Plaintiff's signed consent required..

Complete MSA Bundle: Includes verification of Plaintiff's SSDI and Medicare status; competion of MSA Allocation; conditional payment research; submission of MSA to CMS if desired..

Compromise of Medicare's Conditional Payment: Includes legal argument to support request for reduction or waiver of CMS conditional payment recovery claim; Plaintiff's signed consent required..

Onsite Copy/Scanning: Copy requests should be submitted 24 hours in advance of the appointment day to allow us time to coordinate your service request.