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Referrals
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Referral Form

Date of Referral:*   (MM/DD/YYYY)
 

Referred By:*   

SERVICES REQUESTED:
 
Medicare Set-Aside (MSA) Allocation Please check how you heard about Medivest:
Social Security and Medicare Status Determination
Medicare Conditional Payment ("lien") Investigation
Obtain Social Security and Medicare Releases
Medical Cost Projection
Life Care Plan
Obtain Rated Age
Liability Case Consultation
Settlement Services
Rush Referral (MSA Allocation within 5 business days)		 Existing Medivest customer
Medivest recommended by
Received a marketing call from Medivest
Received information by email from Medivest
Attended a conference presentation by Medivest
Received information by mail from Medivest
Attended a conference where Medivest exhibited
Other (specify)
Coordinate Professional Administration of Medicare Set-Aside Allocation
CLAIMANT INFORMATION:
 
Claim #*:  
Social Security: (xxx-xx-xxxx)      Date of Birth: (MM/DD/YYYY)
Type of Claim:
First Name*:         Last Name*:  
Address:       Address 2:
City:       State:       Zip: -
Phone Number: ( ) -       Email:
Diagnosis Related to this Claim:
State of Jurisdiction:       Date of Injury: (MM/DD/YYYY)
Employer/Insured:
Address:      Address 2:
City:       State:       Zip: -
Phone Number: ( ) -       Email:
 
 
Has a settlement been reached?   Yes   No
If yes, total amount of settlement $

Is mediation scheduled?   Yes   No  

Is claimant currently receiving Social Security?   Yes   No
Is claimant receiving Medicare benefits?   Yes   No
Is claimant currently receiving Medicaid benefits?   Yes   No
Are there any known Medicare conditional payment claims ("liens")?   Yes   No
Is this or any portion of this claim disputed or controverted?   Yes   No
Explain:
Was a Life Care Plan or Medical Cost Projection done?   Yes   No
Is a structured settlement broker involved?   Yes   No
Will the account be professionally administered?   Yes   No
List any known condition that is not related to the injury being settled:
Additional comments:
Who should the completed report be sent to? How would you like the final report to be sent?
Carrier Defense Counsel E-mail
TPA Plaintiff Counsel Fax
Servicing Agent or Adjuster Express Mail
   
PAYER INFORMATION:
 
Contact Person's First Name*:         Last Name*:  
Company Name:
Address*:         Address 2:
City*:         State*:         Zip*:   -
Phone Number*: ( ) -         Fax: ( ) -
Emai*l:  
DEFENSE COUNSEL:
 
First Name:       Last Name:
Firm Name:
Address:       Address 2:
City:       State:       Zip: -
Phone Number: ( ) -       Fax: ( ) -
Email:
PLAINTIFF COUNSEL:
 
First Name:       Last Name:
Firm Name:
Address:       Address 2:
City:       State:       Zip: -
Phone Number: ( ) -       Fax: ( ) -
Email:
SETTLEMENT BROKER:
 
Is there a Settlement Broker currently working on this case?
(If Yes, complete section below)
 
First Name:       Last Name:
Company Name:
Address:       Address 2:
City:       State:       Zip: -
Phone Number: ( ) -       Fax: ( ) -
Email:
FOR PROFESSIONAL ADMINISTRATION:
 
Please provide the following information if you are considering Professional Administration of the
Medicare Set-Aside Allocation:

How is the Medicare Set-Aside Account being funded?

  • By a Single Lump Sum Deposit at the Time of Settlement
    Amount: $
  • By a Structured Settlement with Periodic Payments into the Account
    Name of Annuity Issuer:
    Initial Funding Amount: $
    Annual Annuity Amount: $

Please provide the following information if you are considering a Medical Custodial Account for non-Medicare allowable expenses:

  1. How is the Medical Custodial Account being funded?
    • By a Single Lump Sum Deposit at the time of Settlement
      Amount: $
    • By a Structured Settlement with Periodic Payments into the Account
      Name of Annuity Issuer:
      Initial Funding Amount: $
      Annual Annuity Amount: $
  2. Will there be any periodic distributions?  Yes  No
    If yes, list the Amount and Frequency of Payments:
  3. Indicate the specific future medical expenses covered under this agreement:
  4. Indicate any restrictions OR exclusions to coverage:
  5. Duration Terms of the Agreement:
  6. Upon death of the Claimant, who will receive any remaining account funds?
  7. If Account is reversionary to the Payer, please provide:
    % Reversionary to Payer:
    Tax I.D. Number:

Comments:

REQUIRED DOCUMENTS:
 
If you already have an MSA allocation, please forward it to Medivest at the address below.
If Medivest is providing the allocation, please forward the following items:
 
  • Initial notice of injury and records for treatment
  • Printed medical claims and indemnity payment history
  • Medical records (3-5 years)
  • Original signed releases authorizing communication with Medicare/Social Security, if obtained
  • All hospital discharge summaries, admission histories and physician reports
  • Medication and DME ledger/run
  • Rated age on life company letterhead, if obtained
 
Please forward to: Medivest
P.O. Box 622945
Oviedo, FL 32762-2945		 Phone: 877-725-2467
Fax: 407-971-4742
E-Mail: sales@medivest.com
     
For express mail: 2100 Alafaya Trail, Suite 201
Oviedo, FL 32765-9418
 

 

 

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