Medicare Set-Aside Evaluation Referral Form

Referral Type

Referring Contact Information
Name
Address
City
State
Zip
Email
Phone
Fax
Claimant Information
Name
Claim Number
Address
City
State
Zip
Date of Birth
Social Security Number
Employer
Date of Injury
State of Loss / Venue
Claimant's Counsel Information
Name
Phone
Address
City
State
Zip
Employer's Counsel Information
Name
Phone
Address
City
State
Zip
Additional Information
AWW $
TTD Rate $
PPD Rate $
TTD Paid $
Medicals Paid To Date $
P&S/MMI
 Yes No
PD%
PD $
What was the Claimant's job at the time of loss?
Please give a description of the loss causing event
What is the nature of the accepted injury?
Approximate Settlement Value $
Is the Claimant Receiving SSD Benefits? Yes No
Is the Claimant Medicare Eligible? Yes No
I will be sending all pertinent records* Please stop by my office and copy the material you need
 
*Please provide the following records:
• Employers First Report of Injury
• Doctor’s First report of Injury
• Any Surgical and Diagnostic test results
• Last three years of Medical reports
• Applications for Adjudication (CA claims)
• Payout History for Medical & Indemnity
• Any Settlement documents
• Prescription invoices or history for the last year
 


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