Get Online Form - Tower Msa Partners

Filling out the Online Form - Tower MSA Partners can facilitate effective management of Medicare Set-Aside (MSA) referrals. This guide will walk you through each section of the form to ensure that you provide all necessary information accurately.

Follow the steps to complete the Online Form successfully.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin with the claimant information section. Fill in the claimant’s first and last name, carrier, board number, date of birth (DOB), and jurisdiction. Ensure accuracy as this data is crucial for identification.
3. Continue with the next part of the claimant information by entering the claim number, social security number, and date of injury (DOI) in the designated fields.
4. In the client information section, provide the client’s first and last name, address, state, phone number, and fax number.
5. Fill out the defense attorney's details. Enter the attorney's first name, address, state, phone number, and fax number.
6. For the claimant attorney information, repeat the process by providing the relevant attorney's information in the same manner as above.
7. Complete the employer details by including the employer's name and contact information.
8. Proceed to the other information section. Here, include the referring adjuster, employer address, employer email, claimant’s counsel, compensable injury, and any details concerning the proposed settlement.
9. Review the documents submitted section. Indicate if you are submitting medical records, payment printouts, first report of loss, proposed lump sum settlement documents, or available legal documents by marking the appropriate checkboxes.
10. In the work requested section, check any boxes applicable to the services being requested, such as Medicare set-aside allocation report, conditional payment lien analysis, obtaining CMS approval, or SS/Medicare verification.
11. If you have additional comments, use the provided space to enter any other relevant information or questions.
12. Once you have completed all sections, you can save your changes, download, print, or share the form as needed.

Complete your documents online now to streamline your MSA referrals.