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Medicare Set-Aside

To request Medicare Set-Aside service, fill out the form below.

Note: Required fields are marked with an asterisk ( * ).

Service Request Date 

Referral Form Medical records for past 3 years
FROI Signed release/consent forms
Medical Claims Payout History for past 2 years Pharmacy and DME history for past 3 years

Type of Referral (Please check appropriate box)

WORKERS COMP
LIABILITY

Medicare Set-Aside
CMS Submission
Life Care Plan
Full Medical Cost Projection
Brief Medical Cost Projection

SS/Medicare Verification

Referral Source

Adjuster Name: *
Phone: *
E-mail: *
Carrier/TPA: *
Address: *
City: *
State: *
ZIP: *
Preferred Annuity Company
for Rated Age:
Pharmacy Vendor:

Claimant Information
Name: *
Phone: *
Address: *
City: *
State: *
ZIP: *
Claim Number: *
State of Jurisdiction: *
Diagnosis: *
Date of Birth: *
Date of Injury: *

Employer Information
Employer: *
Address: *
Phone: *

Attorney Information
Plaintiff Attorney:
Phone:
Fax:
Address:
City:
State:
ZIP:
Email:
   
Defense Attorney:
Phone:
Fax:
Address:
City:
State:
ZIP:
Email:
   
Notes/Special
Handling Instructions:
 



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Madisonville, LA 70447

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