Get Medicare Set-aside Referral Form Workers - Gould & Lamb

Filling out the Medicare set-aside referral form online can be a straightforward process if you follow the correct steps. This guide aims to provide clear instructions for users of all backgrounds to ensure accurate completion of the form.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin with the case information section. Enter the claimant's name, date of birth, address, city, state, zip code, social security number, and gender. Ensure all fields are filled accurately.
3. In the jurisdiction section, specify the workers' compensation or state jurisdiction. Next, input the injury dates and claim numbers provided.
4. Identify the employer, defendant or insured name, and their address to ensure correct processing.
5. Select the appropriate insurance type, marking either workers' comp, longshore, or liability based on the case specifics.
6. In the MSA service selection section, choose one service that best reflects the claimant's needs. This includes options like MSA Standard Allocation or MSA Complex Allocation.
7. Fill out the proposed settlement amounts, including any attorney fees and the funding options, indicating whether a lump sum or annuity applies.
8. Complete the key contact and billing information with the referring party's details, including their contact and address information.
9. Answer additional questions regarding the claim's status, existing Medicare beneficiaries, and any disputed issues to provide comprehensive context.
10. Review all provided information for accuracy before submitting the form. Ensure that you have included all necessary documentation as specified.
11. Once completed, save your changes, and you may choose to download, print, or share the form as needed.

Start completing your Medicare set-aside referral form online now!