Worker’s Compensation Claim Forms

YOUR INFORMATION

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

I am The :

-- Select --Claimant's AttorneyAdjusterDefense Attorney

CLAIMANT

Gender:

MaleFemale

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

SSDI Beneficiary





Guardian Appointed

EMPLOYER

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

CLAIMANT 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 all appropriate boxes below for the requested services.

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

Determine Medicare status: Includes verification thru SSA inquiry of Insured's SSDI and Medicare status and legal opinion regarding whether or not a MSA is recommended. Claimant's signed SSA release form is 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.

Medicare Recovery Claim Research: Includes inquiries to CMS to obtain conditional payment information; requires Carrier's signed Proof of Representation or Claimant's signed Consent Form.

Submit proposed MSA to CMS: Submission of completed MSA and supporting documentation to CMS for approval. Claimant's signed Consent Form required.

Complete MSA Bundle: Includes verification of Claimant's SSDI and Medicare status, completion of MSA, conditional payment research, submission of MSA to CMS for approval. Claimant's signed Consent Form and SSA Release are required.

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 records, pharmacy summary, payment history since the most recent records provided for original MSA; updated tables based on current pricing and life tables; new rated age if appropriate.

Compromise of Medicare's Conditional Payment: Includes legal argument to support request for reduction or waiver of CMS conditional payment recovery claim; Claimant's signed Consent Form required. Hourly charges applied.

Request for CMS approval of Waiver of MSA ($0 MSA): Additional documentation may be required. Claimant's signed Consent Form required.

Medical Cost Projection: For valuing claim and setting reserves - does not include MSA analysis. Release forms not required. Option to convert to MSA available.

Pharmacy Drug Review: Includes referral to a pharmacist for drug regimen review and recommendations.

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.