Make a Referral

Getting Started…

We will need either the WC Claim Form, Liability Intake form, or Case Management Referral Form. For all Medicare Set-Aside (MSA) and Medical Cost Projection (MCP) referrals, we also need the following:

• Initial treatment report and first report of injury
• Operative notes from procedures conducted prior to the last three years
• Last three years medical records: We do not need physical therapy notes,lab reports, or nurses’ progress notes from hospitalizations. We do need physician office visit notes, operative notes, hospitalization discharge summaries.
• Last two years pharmacy summary: This printout should include drug names, dosages, quantities, and fill dates.
• Last two years claims payment history: This should include both indemnity and medical payments. (If the referral is for a liability claim, we do not expect to receive a payment history.)

If you need the injured individual’s Medicare status, the signed SSA Release is required. If you need the MSA submitted to CMS, the signed Consent Form is required. Should you need to discuss the claim prior to making a referral, please do not hesitate to contact us.