(800) 557-8585 | (407) 677-8585 | (407) 677-7602 Fax Referrals@WorkersRehab.com

MEDICARE SET ASIDES FORM

If you wish to request MSA services, please fill out the form below and press submit. A case management specialist will then contact you to discuss your specific needs and obtain any additional information.

If you need our Proactive Return-to-Work Program Referral Form, please click here.

* notes required fields

 


    REFERRAL SOURCE INFORMATION

    Claim #*
    Company*
    Address*
    City*
    State*
    ZIP*
    Contact*
    Phone #*
    Ext.
    Fax #*
    Email*

     


     

    CLAIMANT INFORMATION

    Name*
    Address*
    City*
    State*
    Phone #*
    D/Referred*
    SSN*
    D/A*
    DOB*

     


     

    DESCRIPTION OF INJURY

    Description of Accident
    Diagnoses

     


     

    PHYSICIAN INFORMATION:

    Name
    Address
    City
    State
    ZIP
    Contact
    Phone #
    Fax #

     


     

    EMPLOYER INFORMATION:

    Name
    Address
    City
    State
    ZIP
    Phone #
    Contact
    Position
    Date of Hire
    Wage Info

     


     

    ATTORNEY INFORMATION:
    Beneficiary's Attorney
    Phone #
    Fax #
    Address
    City
    State
    ZIP
    Insured's Attorney
    Phone #
    Fax #
    Address
    City
    State
    ZIP

     


     

    TYPE OF REFERRAL:

    Medical
    Other

     


     

    SPECIAL INSTRUCTIONS / ADDITIONAL COMMENTS

    SSD Status*
    Medicare Status*
    Potential Settlement Date*
    Comments/Instructions

     


     

    After submitting the MSA form, please email the below to Referrals@WorkersRehab.com:

    • Medical Records – From Date of Injury – or past two to three years.

    • Payment History

    • Prescription Bills

    • Settlement Information and Legal Documents pertaining to claim.

    • Documentation Regarding Medicare and Social Security Disability Status.

    • If you are requesting us to obtain a RATED AGE, please advise.