Please fill out the following form with as much information as is available. Your information will be sent to M Hayes for processing, upon hitting the Submit button when complete. If this case is urgent, please click the urgent check box at the bottom of the form. You can get a hard copy of this form by clicking the print icon before submitting the form. The information submitted is considered confidential and will not be transmitted to any other entity without your permission.

women

1     Requested by

Note: If you have referred before, your address, phone, and e-mail info may be omitted.

2     Claim Information

3     Claimant

Yes     No

4     Employer / Insured

5     Claimant Attorney

Yes     No    Advised     Unknown     Letter

Yes     No

6     Defense Attorney

Yes     No    Advised    


7     Services Rendered

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 )
Medicare set-aside allocation ( Documents needed: Employer's first report of injury or employee claim form, last 3 years of medical records, printout of last two years of medical payments including pharmacy, history, any operative reports, rated age on life insurance company letterhead if applicable and available- We will obtain if necessary )
Check if this is a pre-settlement MSA evaluation
Check if this is a contested case to be evaluated for submission for a $0 allocation to CMS
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 administratioon agreement, if applicable )
Check if you would like us to obtain the CMS consent to release form

8     Type of Coverage

    General Liability
    Other:
    Yes         No

9     Services Requested

Yes     No     Print: