WCMSA Request Form

Fields marked with an asterisk (*) are required.
Requestor Information
Your Name
Firm
Phone #
Email
Services Requested
(Check all that apply) 		Report of WC Claim to Medicare
SS/Medicare Releases for Status; Medicare Lien Verification
Medical Care Cost Projections with Informal MSA
MSA Allocation/Arrangement -- Standard
MSA Allocation/Arrangement -- Complex
MSA Allocation/Arrangement -- Extraordinarily Complex
MSA Submission to Medicare for Approval
Additional Services
(Check all that apply) 		Life Care Plan (LCP) Analysis -- Standard
Life Care Plan Analysis -- Extraordinarily Complex
Critique of Opposing Life Care Plan
Attorney Work Product? Yes No
LCP Amendment? Yes No
Patient/Applicant Information
Name (First Last) *
Address
City, State ZIP ,
Phone
Date of Birth *
Gender Male Female *
Social Security # *
WCAB #
OWCP #
(Longshore only)
OALJ #
(Longshore only)
Court
(Civil/Liability only)
Case #
(Civil/Liability only)
Medicare Entitled To
(Check all that apply) 		A B D
Occupation
Date(s) of Injury/Illness *
Accepted Injury/Illness/Body Parts
Denied/Disputed Injury/Illness/Body Parts
Indicate in Notes/Special Handling section if more space is needed for dates of injuries or injury listing.
Employer Information
Employer Name (First Last)
Firm *
Address
City, State ZIP ,
Phone
Fax
Insurance Carrier/Administrator Information
Name (First Last)
Firm *
Address
City, State ZIP ,
Phone
Fax
Email
Insurance File/Claim # *
Employer Carrier/Attorney Information
Name (First Last)
Firm
Address
City, State ZIP ,
Phone
Fax
Email
Attorney File #
Applicant/Plaintiff Attorney Information
Name (First Last)
Firm *
Address
City, State ZIP ,
Phone
Fax
Email
Structured Settlement Broker Information
Name (First Last)
Firm
Address
City, State ZIP ,
Phone
Fax
Email
File Information
Does the LCP need to be completed on a rush basis? Yes No
If Yes, Date Due
Is the claimant receiving Social Security Disability payments? Yes No Not Known
If Yes, provide documentation.
Has the claimant been denied Social Security Disability? Yes No Not Known
Has the releases been sent to applicant/plaintiff counsel and/or claimant? Yes No Not Known
Has a rated age been obtained? Yes No Not Known
If Yes, provide broker information above.
Has this claim been settled or has a settlement amount been proposed? Yes No Not Known
If Yes, Amount
Who will be handling your CMS submission? MEDLink Other
Additional Information
Notes/Special Handling