(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.