Loading
Get Workers' Compensation Medicare Set-aside Arrangement (wcmsa ... - Cms
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Workers' Compensation Medicare Set-aside Arrangement (WCMSA) online
Navigating the Workers' Compensation Medicare Set-aside Arrangement (WCMSA) form can be straightforward with the right guidance. This guide will provide you with step-by-step instructions to help you accurately fill out the form online.
Follow the steps to complete the WCMSA form with confidence.
- Click ‘Get Form’ button to access the WCMSA form and open it for editing.
- Fill in your name in the designated field at the top of the form.
- Enter your Health Insurance Claim Number (HICN) in the appropriate box.
- Indicate the date on which you are submitting the form.
- Record the total WCMSA amount as noted in the CMS's written opinion.
- Choose one of the two options regarding your WCMSA: either attest that you have used funds from the WCMSA for medical services and prescription drug expenses for the specific period or confirm that you have completely exhausted the funds.
- For the chosen option, provide details of medical services and prescription drug expenses, indicating the amounts spent in the designated fields.
- Sign and date the form to verify the information provided. Have a witness sign and date the form as well.
- Once completed, save changes to the form and prepare to download or print it for mailing to the designated address.
- Make several copies of the completed form for your records and for annual submission to Medicare.
Complete your WCMSA form online today and ensure timely submission.
If someone is not properly spending their MSA funds or not reporting properly, they are jeopardizing their future Medicare benefits for injury-related care. Medicare states it will deny paying for treatments if it cannot track the proper use and exhaustion of the MSA funds.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.