* Note: If you do not want to process the form electronically you may download the form by clicking here. Once you have downloaded the form please forward your referral and all documentation to Rita Ebbeskotte, M Hayes, 9327 Midlothian Tpk., Suite 2E, Richmond, VA 23236; Phone 804-560-2080; Fax 804-560-2085, or email to: msa@mhayes.com.

Referral for Medicare Set-Aside Services
Client Information
Name: Title:
Company or Firm:
Address:
Phone Number: 
Fax Number:
E-Mail Address:
Policy or File #:    
Claimant and Case Information
Last Name: First Name:
Address:
Phone:  
SSN:
Date of Birth:
Date of Injury:
Diagnosis:
Employer or Insured:
Workers Compensation Claim  
Liability Claim
Total Settlement Amount:
Attorney Information
Defense Counsel (name):
Firm Name:
Address:
Phone:
Fax:
E-mail: 
Claimants/Plaintiffs Counsel (name):
Firm Name:
Address:
Phone: 
Fax:
E-mail:

May we contact this attorney (or claimant if not represented) to obtain necessary releases?
Yes  No
Services Requested
status Verification of Social Security/Medicare status or eligibility –strongly recommended to establish a record of status for CMS review criteria (document needed: signed Social Security Administration Consent for Release of Information, Form SSA 3288)
yes Check if you would like us to assist in obtaining the SSA release

yes

 Medicare Set-Aside allocation (documents needed: Employers First Report of Injury or Employee Claim Form, last 3 years of medical records plus all operative reports, printout of last two years of medical payments including pharmacy history, rated age on life insurance company letterhead if applicable and available –we will obtain if necessary)
yes Check if this is a pre-settlement MSA evaluation
yes Check if this is a contested case to be evaluated for submission of a $0 allocation to CMS
yes Submission of MSA to CMS for approval (documents needed: signed CMS Consent to Release Form, copy of proposed settlement agreement or completed settlement detail sheet, annuity proposal or professional administration agreement, if applicable)
yes Check if you would like us to obtain CMS Consent to Release Form