Medicare Set-Aside Assignment Form

Step One: Gather Documents and Info

Please gather the following information and related documents and forward them to our office:

• Original, signed Authorization to Release Information form.
• The First Report of Injury.
• A recent report from the primary treating physician (or, if no recent treatment, an IME report) describing the current medical condition, diagnosis, treatment and a statement of specific medical services and treatment expected in the future, with comments concerning the frequency and duration of the future services and treatment.
• All medical reports and records covering the last two years of treatment and any case management reports prepared during the last two years of treatment.
• Provide the date and nature of all surgical procedures and major medical events that have taken place since the accident date. If possible, include relevant reports.
• A copy of the payment (expense) ledger listing all medical and indemnity payments made by insurer/TPA for the most recent two years including payee name, amount of payment and date of payment. If the ledger is coded, please include an explanation of the codes.
• Any documentation of Maximum Medical Improvement (MMI), impairment ratings, and verification that the claimant’s condition is stable and documentation of the extent of partial or total limitations of disability.
• Expert depositions or any documentation of an injury that is being disputed or compromised (e.g. a medical condition not related to the job injury).

Step Two: MSA Assignment Form

Please fill out the following form as completely and accurately as possible.

IMPORTANT NOTICE: The Centers for Medicare and Medicaid Services (CMS) issues specific and inflexible requirements for Medicare Set-Aside (MSA) proposal submissions. Failure to comply with all requirements could result in the return of the incomplete proposal.

Has the claimant applied for or received Social Security Disability benefits?	Choose One Yes No Unknown Not Applicable
If yes, when did the claimant begin receiving SSDI benefits? (MM/DD/YYYY)
Is the claimant currently a Medicare beneficiary?	Choose One Yes No Unknown Not Applicable
Has MMI been established?	Choose One Yes No Unknown Not Applicable
Has a settlement been reached?	Choose One Yes No Unknown Not Applicable
If “Yes”, what are the settlement terms?
Please specify the services you are requesting (check all that apply): Gather data, estimate MSA amount and report recommendations Obtain Medicare approval of MSA ONLY Determine whether MSA and Medicare approval is required ONLY Verify if Medicare conditional payment claims apply to the workers’ compensation settlement Prepare a comprehensive life care plan (CMS rarely requires a life care plan) Prepare a comprehensive analysis of the cost of future care (Generally provided for reserving purposes) Verify Social Security status and obtain benefit information
Provide Additional Instructions/Comments Here: CLAIMANT INFO
Name:
Date of Birth:
SSN:
Sex:	Please Select Female Male
Email:
Telephone:
Address:
City/State/Zip:
Date of Injury:
Nature of Injury:
City and State Where Injury Occured:
Additional Instructions/Comments:
EMPLOYER INFO
Contact Name:
Company Name:
Address:
City/State/Zip:
Email:
Telephone:
Fax:
INSURANCE / TPA ADJUSTER INFO
Adjuster Name:
Insurance / TPA:
Address:
City/State/Zip:
Email:
Telephone:
Fax:
Estimated Settlement Value:
Claim Number:
CLAIMANT ATTORNEY INFO
Claimant Attorney:
Firm Name:
Address:
City/State/Zip:
Email:
Telephone:
Fax:
EMPLOYER ATTORNEY INFO
Employer Attorney:
Firm Name:
Address:
City/State/Zip:
Email:
Telephone:
Fax: