Get Liability/med-pay/no-fault/pip Allocation Referral Form - Gould & Lamb

Filling out the Liability/med-pay/no-fault/pip Allocation Referral Form is a crucial step in managing claims related to injuries. This guide will provide you with clear, detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the claimant's information in the 'Claim Information' section. Fill in the claimant's full name, date of birth, address, social security number, city, state, and zip code. Indicate the claimant's gender and provide details for the first date of injury, along with the corresponding claim number.
3. Continue to fill in information for any additional injuries. If applicable, enter the second and third dates of injury along with their respective claim numbers. Provide the name and address of the employer, defendant, or insured party, and ensure that the state of jurisdiction is accurate.
4. In the 'Key Contact & Billing Information' section, enter details for the referring party, including their name and telephone number. Additionally, provide information for the insurance carrier, defense attorney, and plaintiff attorney, including their names, telephone numbers, and addresses.
5. Next, navigate to 'Insurer Information' and enter the insurer’s name — this must not be the TPA’s name. Then select the type of insurance that applies: Liability, Med-Pay/No-Fault/PIP.
6. Proceed to the 'MSP Compliance Service Selection' section where you will choose the applicable category based on the claimant's situation. Make your selection carefully as this will impact the processing of the claim.
7. Continue filling in the required fields under 'General File Information.' Answer questions regarding Medicare beneficiary status, Social Security Disability benefits application, total settlement amount, and any associated workers' compensation claims.
8. Address any 'Additional Questions' about denied, disputed, or controverted issues. Provide details on previous injuries, conditions, or disputes related to the claim, as required.
9. Once you have completed the form, review all entered information for accuracy. Make any necessary corrections before proceeding.
10. Finally, save changes, download, print, or share the form as needed. Ensure that you send the completed form and any required documentation to the specified address.

Complete your documents online with confidence and ensure your claims are processed smoothly.