Medicare Set-Aside (MSA) Referral Form

You may submit a referral using the online form below, or download a printable PDF version of the form to complete and send via fax to 919-846-4740, or mail to:
 
Carolina Case Management
118 Wind Chime Court
Raleigh, NC 27615
 
Download PDF Form Here.

CASE INFORMATION
Injured Worker's Name (First, Middle Initial, Last)
 Date of Birth
Address
 Social Security Number
City, State, Zip Code
 Date of Injury
Employer
 Claim Number
Employer Address & Telephone
 Employer Contact Name
Referrer Name (First, Middle Initial, Last)
 Referrer email
KEY CONTACT AND BILLING INFORMATION
REFERRING PARTY 1
Adjuster Name
 Telephone
 Email Address
Insurance Carrier/TPA/Servicing Agent
 Address
REFERRING PARTY 2
Defense Attorney Name
 Telephone
 Email Address
Defense Firm Name
 Address
REFERRING PARTY 3
Plaintiff Attorney Name
 Telephone
 Email Address
Plaintiff Firm Name
 Address
Please provide copies of the allocation report to:
Carrier/TPA/Servicing Agent   Defense Attorney   Plaintiff Attorney   Other - Describe:  
Party Responsible for Bill
Insurance Carrier   Referring Party 		Billing Address & Telephone Number (if different from above)
1. Has the injured worker applied, denied and/or appealing;
    or receiving Social Security Disability payments?		 yes     no     not known
2. Is the injured worker currently a Medicare Beneficiary? yes     no     not known
3. Are there any controverted issues? If so, please note in box below. yes     no     not known
4. Has this claim been settled?
    - If so, please provide settlement papers and method of funding.		 yes     amount:
5. Has a rated age been obtained? yes     no     not known
6. Who will be handling your CM submission? Insurance Carrier/TPA/Servicing Agent
Specialized Legal Counsel
Other - Describe:
7. Please provide a payment history from the date of injury.
    - Has the claim been settled? yes     no     not known
NOTES/SPECIAL HANDLING - (controverted issues, deadlines, mediation/court date, etc)
Incomplete records or delayed receipt of the required documents may delay the processing of your file and may not serve your needs in a timely manner. We will notify you of any missing documentation upon receipt of the file. Carolina Case Management reserves the right to change service selection based on injury type and volume of records upon review and notification to referring party.