Follow the steps to complete the RSA Medical Form.

1. Click ‘Get Form’ button to access the RSA Medical Form and open it in the editor.
2. Begin by filling out the claimant information. Enter the claimant's full name, street address, city, state, zip code, social security number, date of birth, date of injury, state of jurisdiction, employer name, employer address, date of hire, and claim number in the respective fields.
3. Next, move to the referring contact information section. Input the claim professional's name, address, phone number, and email. Indicate the insurance carrier or third-party administrator, along with their address, phone number, and email.
4. If applicable, provide the additional attorney information. Fill in the defense attorney's name, address, phone number, and email, as well as the claimant's attorney information if different.
5. Indicate the claimant's status regarding Medicare and Medicaid by checking yes or no for each option. If applicable, provide the date of Medicare eligibility and whether the claimant's Medicare card is available and attached with the referral.
6. Answer the questions related to Social Security Disability Insurance (SSDI) eligibility by checking the appropriate boxes and providing the date of SSDI eligibility.
7. Provide information on whether the claim has been settled and enter the total settlement amount if it has. Indicate if the claim has been approved and whether it is being considered for a structured settlement.
8. List all accepted injuries along with their dates, as well as any disputed injuries and the reasons for these disputes.
9. Once the form is completed, save your changes. You can then download, print, or share the form as necessary before submitting it to the provided email address.

Start filling out your RSA Medical Form online today for a smooth submission process!