Get Msa Service Request - Gopromed.com

Filling out the MSA Service Request form online is a straightforward process that ensures you provide all necessary information for Medicare Set-Aside services. This guide offers clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the MSA Service Request form.

1. Click the ‘Get Form’ button to access the MSA Service Request form and open it in your browser.
2. In the section titled 'Select Appropriate Service', choose one or more services you are requesting. Options may include 'Complete MSA', 'Allocation Report Only', 'Lien Research', or indicate if you are reopening or updating a previous request.
3. Provide 'Case Information' by entering the claimant's full name (First, Middle Initial, Last), date of birth, address, date of injury, city, state, zip code, jurisdictional state, employer, social security number, and claim number.
4. In the 'Key Contact & Billing Information' section, select the referring party and fill in the required contact details such as adjuster name, location, telephone number, and email address.
5. Select any relevant attorneys (defense or plaintiff). Include their mailing addresses, telephone numbers, and email addresses as needed. Specify where copies of the allocation report should be sent.
6. Proceed to 'File Information' to answer questions related to the claimant's social security benefits status and Medicare beneficiary status. Provide information about releases sent, whether the file has been settled, and other requested details.
7. Indicate the report time frame. Choose 'Routine Turnaround', 'Normal Status', or 'RUSH Status' if applicable. If RUSH is requested, note the date the report is needed.
8. List all 'Documents Needed' for Phase I and Phase II as specified in the form. Ensure to include any special handling instructions in the provided section.
9. Review all filled information to ensure accuracy and completeness before submitting the form.
10. Finally, save your changes, download, print, or share the completed MSA Service Request form as necessary.

Complete your MSA Service Request form online today to ensure timely processing of your request.