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What We Need
Click on the links below to download important documents that we will need to begin your MSA.
Document
Referral Form
Document
General Release
Document
MSPRC Release
Document
Social Security Administration Release

Referral Form

Provides us with important information about all parties involved and compensable components.

General Releases

This release authorizes a representative of Medicare Set-Aside Specialists, Inc. to speak with and obtain information from treating physicians or other health care providers about the claimant's past and future medical and/or psychological care needs/services, including obtaining copies of my medical records, for the purpose of completing a future medical cost projection and/or Medicare Set-Aside allocation.

MSPRC Release (Medicare Consent)

Authorizes CMS, its agents and/or contractors to release, information related to the injury/illness and/or settlement for the specified date of injury/illness to MSA Specialists, Inc.

Social Security Administration Release

Authorizes the release of information that pretains to claimants SSDI entitlement, Medicare date of entitlement for Medicare and basis for entitlement (disability or age).
Click to accessour secure file transfer site