(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.