{"id":511,"date":"2012-02-08T16:41:39","date_gmt":"2012-02-08T16:41:39","guid":{"rendered":"http:\/\/www.medlinkmsalcp.com\/?page_id=511"},"modified":"2026-02-05T18:18:51","modified_gmt":"2026-02-05T18:18:51","slug":"lcp-request-form","status":"publish","type":"page","link":"https:\/\/www.medlinkmsalcp.com\/?page_id=511","title":{"rendered":"LCP Request Form"},"content":{"rendered":"

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Fields marked with an asterisk (*<\/span>) are required.<\/div>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Requestor Information<\/th>\n<\/tr>\n
Your Name<\/td>\n<\/td>\n<\/tr>\n
Firm<\/td>\n<\/td>\n<\/tr>\n
Phone #<\/td>\n<\/td>\n<\/tr>\n
Email<\/td>\n<\/td>\n<\/tr>\n
Services Requested(Check all that apply)<\/td>\nLife Care Plan (LCP) Analysis — Standard
\n Life Care Plan Analysis — Extraordinarily Complex Critique of Opposing Life Care Plan<\/td>\n<\/tr>\n
Attorney Work Product?<\/td>\nYes No<\/td>\n<\/tr>\n
LCP Amendment?<\/td>\nYes No<\/td>\n<\/tr>\n
Patient\/Plaintiff Information<\/th>\n<\/tr>\n
Name (First Last)<\/td>\n *<\/span><\/td>\n<\/tr>\n
Address<\/td>\n<\/td>\n<\/tr>\n
City, State ZIP<\/td>\n, <\/td>\n<\/tr>\n
Phone<\/td>\n<\/td>\n<\/tr>\n
Date of Birth<\/td>\n *<\/span><\/td>\n<\/tr>\n
Gender<\/td>\nMale Female
\n*<\/span><\/td>\n<\/tr>\n
Social Security #<\/td>\n *<\/span><\/td>\n<\/tr>\n
WCAB #
\n(WC only)<\/td>\n		<\/td>\n<\/tr>\n
OWCP #(Longshore only)<\/td>\n<\/td>\n<\/tr>\n
OALJ #(Longshore only)<\/td>\n<\/td>\n<\/tr>\n
Medicare Entitled To(Check all that apply)<\/td>\n A B D<\/td>\n<\/tr>\n
Occupation<\/td>\n<\/td>\n<\/tr>\n
Date(s) of Injury\/Illness<\/td>\n *<\/span>
\n <\/td>\n<\/tr>\n
Accepted Injury\/Illness\/Body Parts<\/td>\n<\/td>\n<\/tr>\n
Denied\/Disputed Injury\/Illness\/Body Parts<\/td>\n<\/td>\n<\/tr>\n
Indicate in Notes\/Special Handling section if more space is needed for dates of injuries or injury listing.<\/td>\n<\/tr>\n
Defendant Information (Civil\/Liability Only)<\/th>\n<\/tr>\n
Name (First Last)<\/td>\n <\/td>\n<\/tr>\n
Employer Information<\/th>\n<\/tr>\n
Employer Name (First Last)<\/td>\n <\/td>\n<\/tr>\n
Firm<\/td>\n<\/td>\n<\/tr>\n
Address<\/td>\n<\/td>\n<\/tr>\n
City, State ZIP<\/td>\n, <\/td>\n<\/tr>\n
Phone<\/td>\n<\/td>\n<\/tr>\n
Fax<\/td>\n<\/td>\n<\/tr>\n
Insurance Carrier\/Administrator Information<\/th>\n<\/tr>\n
Name (First Last)<\/td>\n <\/td>\n<\/tr>\n
Firm<\/td>\n *<\/span><\/td>\n<\/tr>\n
Address<\/td>\n<\/td>\n<\/tr>\n
City, State ZIP<\/td>\n, <\/td>\n<\/tr>\n
Phone<\/td>\n<\/td>\n<\/tr>\n
Fax<\/td>\n<\/td>\n<\/tr>\n
Email<\/td>\n<\/td>\n<\/tr>\n
Insurance File\/Claim #<\/td>\n *<\/span><\/td>\n<\/tr>\n
Employer Carrier\/Attorney Information<\/th>\n<\/tr>\n
Name (First Last)<\/td>\n <\/td>\n<\/tr>\n
Firm<\/td>\n<\/td>\n<\/tr>\n
Address<\/td>\n<\/td>\n<\/tr>\n
City, State ZIP<\/td>\n, <\/td>\n<\/tr>\n
Phone<\/td>\n<\/td>\n<\/tr>\n
Fax<\/td>\n<\/td>\n<\/tr>\n
Email<\/td>\n<\/td>\n<\/tr>\n
Attorney File #<\/td>\n<\/td>\n<\/tr>\n
Applicant\/Plaintiff Attorney Information<\/th>\n<\/tr>\n
Name (First Last)<\/td>\n <\/td>\n<\/tr>\n
Firm<\/td>\n *<\/span><\/td>\n<\/tr>\n
Address<\/td>\n<\/td>\n<\/tr>\n
City, State ZIP<\/td>\n, <\/td>\n<\/tr>\n
Phone<\/td>\n<\/td>\n<\/tr>\n
Fax<\/td>\n<\/td>\n<\/tr>\n
Email<\/td>\n<\/td>\n<\/tr>\n
Structured Settlement Broker Information<\/th>\n<\/tr>\n
Name (First Last)<\/td>\n <\/td>\n<\/tr>\n
Firm<\/td>\n<\/td>\n<\/tr>\n
Address<\/td>\n<\/td>\n<\/tr>\n
City, State ZIP<\/td>\n, <\/td>\n<\/tr>\n
Phone<\/td>\n<\/td>\n<\/tr>\n
Fax<\/td>\n<\/td>\n<\/tr>\n
Email<\/td>\n<\/td>\n<\/tr>\n
File Information<\/th>\n<\/tr>\n
Does the LCP need to be completed on a rush basis?<\/td>\n Yes NoIf Yes, Date Due <\/td>\n<\/tr>\n
Is the claimant receiving Social Security Disability payments?<\/td>\n Yes No Not KnownIf Yes, provide documentation.<\/td>\n<\/tr>\n
Has the claimant been denied Social Security Disability?<\/td>\n Yes No Not Known<\/td>\n<\/tr>\n
Has the releases been sent to applicant\/plaintiff counsel and\/or claimant?<\/td>\n Yes No Not Known<\/td>\n<\/tr>\n
Has a rated age been obtained?<\/td>\n Yes No Not KnownIf Yes, provide broker information above.<\/td>\n<\/tr>\n
Has this claim been settled or has a settlement amount been proposed?<\/td>\n Yes No Not Known
\nIf Yes, Amount <\/td>\n<\/tr>\n
Additional Information<\/th>\n<\/tr>\n
Notes\/Special Handling<\/td>\n