{"id":515,"date":"2012-02-08T16:42:30","date_gmt":"2012-02-08T16:42:30","guid":{"rendered":"http:\/\/www.medlinkmsalcp.com\/?page_id=515"},"modified":"2026-02-05T18:22:10","modified_gmt":"2026-02-05T18:22:10","slug":"wcmsa-request-form","status":"publish","type":"page","link":"https:\/\/www.medlinkmsalcp.com\/?page_id=515","title":{"rendered":"WCMSA Request Form"},"content":{"rendered":"<form id=\"requestForm\" action=\"#\" method=\"POST\">\n    <input type=\"hidden\" id=\"task\" name=\"task\" value=\"save\" \/><br \/>\n<input type=\"hidden\" id=\"g-recaptcha-response\" name=\"g-recaptcha-response\"><br \/>\n<input type=\"hidden\" id=\"import\" name=\"import\" value=\"false\" \/><\/p>\n<p><input type=\"hidden\" name=\"RequestForm__id\" value=\"\" \/><br \/>\n<input type=\"hidden\" name=\"RequestForm__requestType\" value=\"WCMSA\" \/><\/p>\n<div class=\"label\">Fields marked with an asterisk (<span class=\"required\">*<\/span>) are required.<\/div>\n<div class=\"viewForm\">\n<table class=\"field\" cellspacing=\"0\" cellpadding=\"5\">\n<tr>\n<th colspan=\"2\">Requestor Information<\/th>\n<\/tr>\n<tr>\n<td>Your Name<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__requestor_name\" name=\"RequestForm__requestor_name\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<td>Firm<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__requestor_firm\" name=\"RequestForm__requestor_firm\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<td>Phone #<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__requestor_phone\" name=\"RequestForm__requestor_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<td>Email<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__requestor_email\" name=\"RequestForm__requestor_email\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\t\tServices Requested<br \/>\n(Check all that apply)<\/td>\n<td>\n\t\t\t\t\t\t<input type=\"checkbox\" name=\"RequestForm__requestor_service_medicareReportClaim\" value=\"1\" \/> Report of WC Claim to Medicare<\/p>\n<p><input type=\"checkbox\" name=\"RequestForm__requestor_service_medicareLienVerification\" value=\"1\" \/> SS\/Medicare Releases for Status; Medicare Lien Verification<br \/>\n<input type=\"checkbox\" name=\"RequestForm__requestor_service_MSAInformal\" value=\"1\" \/> Medical Care Cost Projections with Informal MSA<br \/>\n<input type=\"checkbox\" name=\"RequestForm__requestor_service_MSAStandard\" value=\"1\" \/> MSA Allocation\/Arrangement &#8212; Standard<br \/>\n<input type=\"checkbox\" name=\"RequestForm__requestor_service_MSAComplex\" value=\"1\" \/> MSA Allocation\/Arrangement &#8212; Complex<br \/>\n<input type=\"checkbox\" name=\"RequestForm__requestor_service_MSAExtraComplex\" value=\"1\" \/> MSA Allocation\/Arrangement &#8212; Extraordinarily Complex<\/p>\n<p><input type=\"checkbox\" name=\"RequestForm__requestor_service_MSASubmission\" value=\"1\" \/> MSA Submission to Medicare for Approval<\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\t\t\t\t\t\t\tAdditional Services<\/p>\n<p>(Check all that apply)<\/td>\n<td>\n\t\t\t\t\t<input type=\"checkbox\" name=\"RequestForm__requestor_service_LCPAnalysisStandard\" value=\"1\" \/> Life Care Plan (LCP) Analysis &#8212; Standard<br \/>\n<input type=\"checkbox\" name=\"RequestForm__requestor_service_LCPAnalysisComplex\" value=\"1\" \/> Life Care Plan Analysis &#8212; Extraordinarily Complex<br \/>\n<input type=\"checkbox\" name=\"RequestForm__requestor_service_LCPCritique\" value=\"1\" \/> Critique of Opposing Life Care Plan<\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Attorney Work Product?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__requestor_attorneyWorkProduct\" value=\"1\" \/>Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__requestor_attorneyWorkProduct\" value=\"0\"  checked=\"checked\" \/>No<\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>LCP Amendment?<\/td>\n<td>\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__requestor_LCPAmendment\" value=\"1\" \/>Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__requestor_LCPAmendment\" value=\"0\"  checked=\"checked\" \/>No<\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Patient\/Applicant Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Name (First Last)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_firstName\" name=\"RequestForm__patient_firstName\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__patient_lastName\" name=\"RequestForm__patient_lastName\" value=\"\" \/><br \/>\n<span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Address<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_address\" name=\"RequestForm__patient_address\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>City, State ZIP<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_city\" name=\"RequestForm__patient_city\" value=\"\" \/>,<br \/>\n<input type=\"text\" id=\"RequestForm__patient_state\" name=\"RequestForm__patient_state\" class=\"state\" value=\"\" \/><\/p>\n<p><input type=\"text\" id=\"RequestForm__patient_zip\" name=\"RequestForm__patient_zip\" class=\"zip\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Phone<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_phone\" name=\"RequestForm__patient_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Date of Birth<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_birthDate\" name=\"RequestForm__patient_birthDate\" class=\"date\" value=\"\" \/><br \/>\n<span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Gender<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__patient_gender\" id=\"RequestForm__patient_gender_M\" value=\"M\" \/>Male<br \/>\n<input type=\"radio\" name=\"RequestForm__patient_gender\" id=\"RequestForm__patient_gender_F\" value=\"F\" \/>Female<br \/>\n<span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Social Security #<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_ssn\" name=\"RequestForm__patient_ssn\" value=\"\" \/><br \/>\n<span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\t\t\t\t\tWCAB #<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_WCABNum\" name=\"RequestForm__patient_WCABNum\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\tOWCP #<\/p>\n<p>(Longshore only)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_OWCPNum\" name=\"RequestForm__patient_OWCPNum\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\tOALJ #<\/p>\n<p>(Longshore only)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_OALJNum\" name=\"RequestForm__patient_OALJNum\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\t\tCourt<\/p>\n<p>(Civil\/Liability only)<\/td>\n<td>\n\t\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_court\" name=\"RequestForm__patient_court\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\t\tCase #<\/p>\n<p>(Civil\/Liability only)<\/td>\n<td>\n\t\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_caseNum\" name=\"RequestForm__patient_caseNum\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\tMedicare Entitled To<\/p>\n<p>(Check all that apply)<\/td>\n<td>\n\t\t\t\t\t<input type=\"checkbox\" name=\"RequestForm__patient_medicareEntitledToA\" value=\"1\" \/> A<br \/>\n<input type=\"checkbox\" name=\"RequestForm__patient_medicareEntitledToB\" value=\"1\" \/> B<br \/>\n<input type=\"checkbox\" name=\"RequestForm__patient_medicareEntitledToD\" value=\"1\" \/> D<\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Occupation<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_occupation\" name=\"RequestForm__patient_occupation\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Date(s) of Injury\/Illness<\/td>\n<td>\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_dateOfInjury1\" name=\"RequestForm__patient_dateOfInjury1\" class=\"date\" value=\"\" \/><br \/>\n<span class=\"required\">*<\/span><br \/>\n<input type=\"text\" id=\"RequestForm__patient_dateOfInjury2\" name=\"RequestForm__patient_dateOfInjury2\" class=\"date\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__patient_dateOfInjury3\" name=\"RequestForm__patient_dateOfInjury3\" class=\"date\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__patient_dateOfInjury4\" name=\"RequestForm__patient_dateOfInjury4\" class=\"date\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__patient_dateOfInjury5\" name=\"RequestForm__patient_dateOfInjury5\" class=\"date\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Accepted Injury\/Illness\/Body Parts<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_acceptedInjury\" name=\"RequestForm__patient_acceptedInjury\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Denied\/Disputed Injury\/Illness\/Body Parts<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__patient_deniedInjury\" name=\"RequestForm__patient_deniedInjury\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td colspan=\"2\" style=\"text-align: center\">\n\t\t\t\t\tIndicate in Notes\/Special Handling section if more space is needed for dates of injuries or injury listing.<\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Employer Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Employer Name (First Last)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employer_firstName\" name=\"RequestForm__employer_firstName\" value=\"\" \/><\/p>\n<p><input type=\"text\" id=\"RequestForm__employer_lastName\" name=\"RequestForm__employer_lastName\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>\n\t\t\t\t\tFirm<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employer_firm\" name=\"RequestForm__employer_firm\" value=\"\" \/><\/p>\n<p><span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Address<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employer_address\" name=\"RequestForm__employer_address\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>City, State ZIP<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employer_city\" name=\"RequestForm__employer_city\" value=\"\" \/>,<br \/>\n<input type=\"text\" id=\"RequestForm__employer_state\" name=\"RequestForm__employer_state\" class=\"state\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__employer_zip\" name=\"RequestForm__employer_zip\" class=\"zip\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Phone<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employer_phone\" name=\"RequestForm__employer_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Fax<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employer_fax\" name=\"RequestForm__employer_fax\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Insurance Carrier\/Administrator Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Name (First Last)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_firstName\" name=\"RequestForm__insurance_firstName\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__insurance_lastName\" name=\"RequestForm__insurance_lastName\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Firm<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_firm\" name=\"RequestForm__insurance_firm\" value=\"\" \/><br \/>\n<span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Address<\/td>\n<td>\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_address\" name=\"RequestForm__insurance_address\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>City, State ZIP<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_city\" name=\"RequestForm__insurance_city\" value=\"\" \/>,<br \/>\n<input type=\"text\" id=\"RequestForm__insurance_state\" name=\"RequestForm__insurance_state\" class=\"state\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__insurance_zip\" name=\"RequestForm__insurance_zip\" class=\"zip\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Phone<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_phone\" name=\"RequestForm__insurance_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Fax<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_fax\" name=\"RequestForm__insurance_fax\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Email<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_email\" name=\"RequestForm__insurance_email\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Insurance File\/Claim #<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__insurance_fileNum\" name=\"RequestForm__insurance_fileNum\" value=\"\" \/><\/p>\n<p><span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Employer Carrier\/Attorney Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Name (First Last)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_firstName\" name=\"RequestForm__employerAttorney_firstName\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__employerAttorney_lastName\" name=\"RequestForm__employerAttorney_lastName\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Firm<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_firm\" name=\"RequestForm__employerAttorney_firm\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Address<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_address\" name=\"RequestForm__employerAttorney_address\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>City, State ZIP<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_city\" name=\"RequestForm__employerAttorney_city\" value=\"\" \/>,<br \/>\n<input type=\"text\" id=\"RequestForm__employerAttorney_state\" name=\"RequestForm__employerAttorney_state\" class=\"state\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__employerAttorney_zip\" name=\"RequestForm__employerAttorney_zip\" class=\"zip\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Phone<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_phone\" name=\"RequestForm__employerAttorney_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Fax<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_fax\" name=\"RequestForm__employerAttorney_fax\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Email<\/td>\n<td>\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_email\" name=\"RequestForm__employerAttorney_email\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Attorney File #<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__employerAttorney_fileNum\" name=\"RequestForm__employerAttorney_fileNum\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Applicant\/Plaintiff Attorney Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Name (First Last)<\/td>\n<td>\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_firstName\" name=\"RequestForm__applicantAttorney_firstName\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__applicantAttorney_lastName\" name=\"RequestForm__applicantAttorney_lastName\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Firm<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_firm\" name=\"RequestForm__applicantAttorney_firm\" value=\"\" \/><\/p>\n<p><span class=\"required\">*<\/span><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Address<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_address\" name=\"RequestForm__applicantAttorney_address\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>City, State ZIP<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_city\" name=\"RequestForm__applicantAttorney_city\" value=\"\" \/>,<br \/>\n<input type=\"text\" id=\"RequestForm__applicantAttorney_state\" name=\"RequestForm__applicantAttorney_state\" class=\"state\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__applicantAttorney_zip\" name=\"RequestForm__applicantAttorney_zip\" class=\"zip\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Phone<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_phone\" name=\"RequestForm__applicantAttorney_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Fax<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_fax\" name=\"RequestForm__applicantAttorney_fax\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Email<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__applicantAttorney_email\" name=\"RequestForm__applicantAttorney_email\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Structured Settlement Broker Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Name (First Last)<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_firstName\" name=\"RequestForm__broker_firstName\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__broker_lastName\" name=\"RequestForm__broker_lastName\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Firm<\/td>\n<td>\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_firm\" name=\"RequestForm__broker_firm\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Address<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_address\" name=\"RequestForm__broker_address\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>City, State ZIP<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_city\" name=\"RequestForm__broker_city\" value=\"\" \/>,<br \/>\n<input type=\"text\" id=\"RequestForm__broker_state\" name=\"RequestForm__broker_state\" class=\"state\" value=\"\" \/><br \/>\n<input type=\"text\" id=\"RequestForm__broker_zip\" name=\"RequestForm__broker_zip\" class=\"zip\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Phone<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_phone\" name=\"RequestForm__broker_phone\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Fax<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_fax\" name=\"RequestForm__broker_fax\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Email<\/td>\n<td>\n\t\t\t\t\t<input type=\"text\" id=\"RequestForm__broker_email\" name=\"RequestForm__broker_email\" value=\"\" \/><\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">File Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Does the LCP need to be completed on a rush basis?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_rush\" value=\"1\" \/> Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__file_rush\" value=\"0\"  checked=\"checked\" \/> No<\/p>\n<p>If Yes, Date Due<br \/>\n<input type=\"text\" id=\"RequestForm__file_rushDueDate\" name=\"RequestForm__file_rushDueDate\" class=\"date\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Is the claimant receiving Social Security Disability payments?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_claimantReceivingDisabilityPayments\" value=\"Y\" \/> Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__file_claimantReceivingDisabilityPayments\" value=\"N\" \/> No<br \/>\n<input type=\"radio\" name=\"RequestForm__file_claimantReceivingDisabilityPayments\" value=\"U\" \/> Not Known<\/p>\n<p>If Yes, provide documentation.<\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Has the claimant been denied Social Security Disability?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_claimantDeniedDisability\" value=\"Y\" \/> Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__file_claimantDeniedDisability\" value=\"N\" \/> No<br \/>\n<input type=\"radio\" name=\"RequestForm__file_claimantDeniedDisability\" value=\"U\" \/> Not Known<\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Has the releases been sent to applicant\/plaintiff counsel and\/or claimant?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_releasesSent\" value=\"Y\" \/> Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__file_releasesSent\" value=\"N\" \/> No<br \/>\n<input type=\"radio\" name=\"RequestForm__file_releasesSent\" value=\"U\" \/> Not Known<\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Has a rated age been obtained?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_ratedAgeObtained\" value=\"Y\" \/> Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__file_ratedAgeObtained\" value=\"N\" \/> No<br \/>\n<input type=\"radio\" name=\"RequestForm__file_ratedAgeObtained\" value=\"U\" \/> Not Known<\/p>\n<p>If Yes, provide broker information above.<\/td>\n<\/tr>\n<tr class=\"altStripe\">\n<td>Has this claim been settled or has a settlement amount been proposed?<\/td>\n<td>\n\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_settlementProposed\" value=\"Y\" \/> Yes<br \/>\n<input type=\"radio\" name=\"RequestForm__file_settlementProposed\" value=\"N\" \/> No<br \/>\n<input type=\"radio\" name=\"RequestForm__file_settlementProposed\" value=\"U\" \/> Not Known<br \/>\nIf Yes, Amount<br \/>\n<input type=\"text\" id=\"RequestForm__file_settlementAmount\" name=\"RequestForm__file_settlementAmount\" value=\"\" \/><\/td>\n<\/tr>\n<tr class=\"stripe\">\n<td>Who will be handling your CMS submission?<\/td>\n<td>\n\t\t\t\t\t\t<input type=\"radio\" name=\"RequestForm__file_whoHandlesCMS\" value=\"MEDLink\" \/> MEDLink<br \/>\n<input type=\"radio\" name=\"RequestForm__file_whoHandlesCMS\" value=\"Other\" \/> Other<\/td>\n<\/tr>\n<tr>\n<th colspan=\"2\">Additional Information<\/th>\n<\/tr>\n<tr class=\"stripe\">\n<td>Notes\/Special Handling<\/td>\n<td>\n\t\t\t\t\t<textarea id=\"RequestForm__additional_notes\" name=\"RequestForm__additional_notes\" cols=\"40\" rows=\"5\"><\/textarea><\/td>\n<\/tr>\n<\/table>\n<div class=\"controls\">\n\t\t\t\t\t\t\t<input type=\"submit\" value=\"Submit Request\" onclick=\"return validateRequestForm()\" name=\"submit\" \/><\/div>\n<\/div>\n<\/form>\n","protected":false},"excerpt":{"rendered":"<p>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 &#8212; Standard MSA Allocation\/Arrangement &#8212; Complex MSA Allocation\/Arrangement &#8212; Extraordinarily Complex [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"tpl-LCP-RequestForm.php","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=\/wp\/v2\/pages\/515"}],"collection":[{"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=515"}],"version-history":[{"count":3,"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=\/wp\/v2\/pages\/515\/revisions"}],"predecessor-version":[{"id":589,"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=\/wp\/v2\/pages\/515\/revisions\/589"}],"wp:attachment":[{"href":"https:\/\/www.medlinkmsalcp.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=515"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}