Referral Form Submit your referral and upload the documents after submission Submit Documents *Select Line of Business* No Fault Work Comp Liability Claimant Information First Name Last Name Street Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Date of Birth SSN Gender Select Male Female Other Claim Information Claim Number Accepted Injuries Date of Injury Denied Injuries Jurisdiction Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Jones Act USL&H Reason for Denial Client/Referring Party Information First Name Last Name Company Name Email Address Street Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Number Carrier Name Employer Name Defense Attorney Information First Name Last Name Company Name Email Address Phone Number Plaintiff Attorney Information First Name Last Name Company Name Email Address Phone Number Select Requested Services Medicare Set-Aside Services Workers’ Comp MSA (WCMSA) Liability MSA Indemnified MSA (iMSA) Indemnified Liability MSA (iLMSA) Abbreviated MSA (aMSA) – With Indemnification Abbreviated MSA (aMSA) – Without Indemnification Evidence-Based MSA (eMSA) Legal Compromise MSA Standard Medical Projection Medical Cost Projection Pre-MSA Report Evaluate for Zero Allocation Submit to CMS Two-Day Rush Fee Five-Day Rush Fee Conditional Payment Services Conditional Payment Verification Conditional Payment Evaluation Conditional Payment Update Dispute / Appeal Secure Final Demand / Case Closure QIC Appeal ALJ Appeal Conditional Payment (CP) Escalation Medicare Advantage / Prescription Drug Plan Lien Services Verification Lien Investigation Lien Evaluation Lien Negotiation Secure Final MAP Lien Demand Medicaid Lien Services Lien Investigation Lien Evaluation Lien Negotiation Secure Final Demand Healthcare Lien Services (TriCare, VA, ERISA, FEHBA, etc.) Lien Investigation Lien Evaluation Lien Negotiation Secure Final Lien Demand Other Services Settlement Agreement Review Legal Consulting MSP Compliance Opinion Letter Medical Mitigation Medicare Eligibility Verification SSDI Eligibility Verification Rated Age Benefits Coordination SSN / DOB Research Other: Additional Comments or Special Instructions Documents Requested Medical Records – Including IME, QME, and 2nd Opinions (Past 2 Years) Prescription History – Including Drug Names and Dosages (Current 2 Years) Medical Payment History & Indemnity Printouts (Current 2 Years) First Report of Injury – Including Description of Injury Proposed Lump Sum Settlement Documents (If Applicable) Applicable Legal Documents Pertaining to Compensability Submit Claimant Information First Name Last Name Street Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Date of Birth SSN Gender Select Male Female Other Claim Information Claim Number Policy Limit Date of Injury Is the Policy Exhausted? Select Yes No Jurisdiction Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Jones Act USL&H Accepted Injuries Client/Referring Party Information First Name Last Name Company Name Email Address Street Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Number Select Services Conditional Payment Services Conditional Payment Verification Conditional Payment Evaluation Conditional Payment Dispute / Appeal Conditional Payment Update Secure Final Demand / Case Closure QIC Appeal ALJ Appeal Conditional Payment (CP) Escalation Medicare Advantage / PDP Services Verification Lien Investigation Lien Evaluation Lien Negotiation Final MAP Lien Demand Medicaid Lien Services Medicaid Lien Investigation Medicaid Lien Evaluation Medicaid Lien Negotiation Secure Final Medicaid Demand Other Services Settlement Agreement Review Legal Consulting Medicare Eligibility Verification SSDI Status Verification SSN / DOB Verification Other: Additional Comments or Special Instructions Documents Requested First Report of Loss – Including Description of Injury Declaration Page Payment Ledger Applicable Medical Records Applicable Legal Documents Submit Plaintiff/Injured Party Information First Name Last Name Street Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Date of Birth SSN Gender Select Male Female Other Claim Information Claim Number Jurisdiction Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Jones Act USL&H Date of Injury Alleged Injuries Client/Referring Party Information First Name Last Name Company Name Email Address Street Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Number Carrier Name Defense Attorney Information First Name Last Name Company Name Email Address Phone Number Plaintiff Attorney Information First Name Last Name Company Name Email Address Phone Number Select Services Medicare Set-Aside (MSA) Services Liability MSA Indemnified Liability MSA Legal Compromise MSA CMS Submission Medicare Advantage / PDP Services Verification Lien Investigation Lien Evaluation Lien Negotiation Secure Final MAP Lien Demand Medicaid Lien Services Lien Investigation Lien Evaluation Lien Negotiation Secure Final Demand Other Services Settlement Agreement Review Legal Consulting MSP Opinion Letter Medical Mitigation Medicare Eligibility Verification Rated Age Benefits Coordination SSD Verification SSN/DOB Research Other: Additional Comments or Special Instructions Documents Requested Medical Records for the Past Two Years Incident Report – Including Description of Injury Proposed Settlement Documents (If Applicable) Applicable Legal Documents Submit
