Refer-a-Case

Please fill in the form below. If there is information that you do not have, you may leave it blank or if any of the required* fields do not apply, please enter n/a. When you have completed the form, click “submit” at the bottom of the page and your information will be securely submitted to a representative. If you have problems or questions while filling out this form, feel free to contact support@msasettlements.com for assistance or call 800.49.SETTLE.

REFER-A-CASE FORM

FIELDS MARKED WITH AN * ARE REQUIRED

Note: if any of the required* fields do not apply, please enter n/a.

Referral contact information (Person submitting referral)

REFERRAL TYPE- PLEASE SELECT THE TYPE OF REFERRAL

TYPE OF REFERRAL *

Medicare Set-Aside ReferralMedical Cost Projection Referral

For us to process your referral quickly we will need the following information.

Report of injury
Claims medical payout ledger
Pharmacy payout ledger
Last 2 years of medical records from all authorized treating providers
Any claims denials/Controverts
List of accepted body parts
Claimant demographics including first name, last name, address, home phone, SSN, DOB and Medicare Number if available
Defense and Plaintiff attorney information including Firm name, attorney name, address, phone and email
Employer name, address, phone and email
Carrier name, contact person (adjuster), address, phone, email and claim number

For us to process your referral quickly we will need the following information.

Report of injury/Accident Crash report
Claims medical payout ledger (If Liability this is not required)
Pharmacy payout ledger (If Liability this is not required)
Last 2 years of medical records from all authorized treating providers
Any claims denials/Controverts
List of accepted body parts
Claimant demographics including first name, last name, address, home phone, SSN, DOB and Medicare Number if available
Defense and Plaintiff attorney information including Firm name, attorney name, address, phone and email
Employer name, address, phone and email
Carrier name contact person (adjuster), address, phone, email and claim number. If there are multiple carriers involved in a Liability claim, please list all carriers.

INJURED WORKER INFORMATION

Note: if any of the required* fields do not apply, please enter n/a.

Date Of Birth*

Gender *

MaleFemale

PLAINTIFF ATTORNEY

Note: if any of the required* fields do not apply, please enter n/a.

INSURANCE CARRIER

Note: if any of the required* fields do not apply, please enter n/a.

Date of Injury*

EMPLOYER INFORMATION

Note: if any of the required* fields do not apply, please enter n/a.

DEFENSE ATTORNEY

Note: if any of the required* fields do not apply, please enter n/a.

ADDITIONAL INFORMATION

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