SECTION 2: MEDICARE SET-ASIDE INFORMATION

MEDICARE CONDITIONAL PAYMENT & SET-ASIDE INTAKE FORM
MSA ALLOCATION PROPOSAL & SUMMARY
MSA SUBMISSION
DATE OF REQUEST:
So that Precision may begin processing your file immediately, please submit this completed form along with the following
documents to intake@precisionlienresolution.com:
Executed CMS Proof of Representation Form
Precision Resolution, LLC Proof of Representation Language copied onto your firm’s letterhead and executed by the
retaining attorney
MOTOR VEHICLE ACCIDENT:
NO-FAULT CARRIER FULL & PROPER NAME:
CARRIER ADDRESS
POLICY #
CLAIM #
MIGHT APIP BE OBLIGATED TO PAY MEDICALS?
IF YES, APIP CARRIER FULL & PROPER NAME:
CARRIER ADDRESS
POLICY #
CLAIM #
EXPOSURE
SLIP & FALL
:
NURSING HOME NEGLIGENCE
PRODUCT LIABILITY
OTHER:
LIABILITY CARRIER FULL & PROPER NAME:
CARRIER ADDRESS
IF YES:
PART A
PART B
MEDICARE ENTITLEMENT DATE
PART C
PART D
POLICY #
CLAIM #
IS THERE A WORKERS’ COMPENSATION CLAIM?
WORKERS’ COMPENSATION CARRIER FULL & PROPER NAME:
CARRIER ADDRESS
POLICY #
CLAIM #
SECTION 2: MEDICARE SET-ASIDE INFORMATION
PLEASE EMAIL THE FOLLOWING DOCUMENTS
(IF READILY AVAILABLE)
PROOF
P
OF REPRESEN
NTATION
The u
undersigned Medicare beneficiary
b
in
nforms the Centers
C
for Medicare & Medicaid S
Services (CMS) that they
have g
given the sp
pecified lega
al representa
ative the autthority to rep
present them
m and act on
n their behalf with respe
ect
to anyy claims for liability insu
urance, no-fa
ault insuranc
ce, or worke
ers compenssation, including releasing identifiab
ble
health
h information
n or resolvin
ng any pote
ential recove
ery claim th
hat Medicare
e may have
e if there is a settlement,
judgm
ment, award,, or other payment.
p
Th
he undersig
gned repressentative ag rees that th
hey represe
ent the stated
Mediccare beneficiary.
e of Represe
entative:
Type
Authorized
d Representtative:
( ) Individual other
o
than an
n Attorney:
( X ) Attorney
( ) Guardian*
( ) Conservato
or*
( ) Power of Atttorney*
__________
__________
__________
___________
_________
(Attorney/ L
Law Firm Na me)
__________
__________
__________
___________
_________
(Law Firm A
Address)
__________
__________
__________
___________
_________
(Law Firm C
City, State, Z
Zip)
__________
__________
__________
___________
_________
(Phone Nu mber)
* If the
e beneficiary is
s incapacitate
ed, his/her gu
uardian, conse
ervator, powe
er of attorney etc. will need
d to submit
docum
mentation in ad
ddition to this
s proof of reprresentation.
Medic
care Benefic
ciary Inform
mation:
Benefficiary’s Nam
me
(pleas
se print exa
actly as sho
own on yourr Medicare card):
c
_ _________
___________
__________
______
Benefficiary’s Health Insurance Claim Num
mber
(numb
ber on Medicare card)::
_ _________
___________
__________
______
Date o
of Illness/Inju
ury for whic
ch the benefficiary has filed a
liabilitty insuranc
ce, no-fault insurance or
o workers’
comp
pensation cllaim:
_
__________
___________
__________
______
Benefficiary’s Sign
nature: ____
___________
__________
___________
___
Date ssigned: ____
___________
_______
Repre
esentative’s Signature: ___________
_
__________
__________
___
Date ssigned: ____
___________
_______
GFRG-2010
Medicare Secondary Payer Recovery Contractor
MSPRC-NGHP
Post Office Box 138832
Oklahoma City, OK 73113
PRECISION RESOLUTION, LLC
PROOF OF REPRESENTATION
RE:
Beneficiary:
HIC#:
Date of Incident:
Dear Sir or Madam:
Please be advised that
, the attorney for the
above referenced Medicare beneficiary, has appointed Precision Resolution, LLC as
representative regarding the resolution of any Medicare conditional payment issues pertaining
to this file. Please provide Precision Resolution, LLC with any information regarding this
claim to the following address:
Precision Resolution, LLC
3686 Seneca Street
Buffalo, NY 14224
Signature of Beneficiary’s Attorney: __________________________________________
Date:
Representative’s Signature: _______________________________________
Paul R. Loudenslager, Esq.
Precision Resolution, LLC
Date: