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  * DENOTES A REQUIRED FIELD
   
Service Being Requested Medicare Lien Verification
MSA
Medical Cost Projection
Social Security Verification
   
Adjuster Information
Name *
Address Line 1
Address Line 2
City
State
Zip
Phone Number *
Email Address *
   
Claimant Logistic Information
Name *
Date of Injury *
Claim Number
Address Line 1
Address Line 2
City
State
Zip
SS# *
DOB
Employer
Claimant's Counsel's Contact Information
Defense's Counsel's Contact Information
   
Claimant Case Information
How did injury occur?
What was the specific nature of the accepted injury?
Please give title and brief description of the Claimant’s job at the time of injury?
Is Claimant currently recieving Social Security Disability benefits?
Is Claimant currently eligible to recieve Medicare benefits?
What is the total amount of indemnity benefits paid to date and does Claimant continue to recieve such benefits?
What is the total amount of medical benefits paid to date?
Has a settlement been reached? If yes, please provide amount of settlement?
How is set aside to be paid? Out of settlement proceeds
Above and beyond settlement proceeds
   
Documentation Checklist

Please upload the following copies (DO NOT SEND ORGINIAL DOCUMENTATION):

File size is limited to 5MB per document.







  • Records/reports from Claimant’s treating physician or physicians from past two (2) years. (if records are voluminous, please send those that most accurately describe Claimant’s treatment and current physical status.)
  • IME reports from past three (3) years.
  • Print out of payment history OR medical benefits for the last 3 years or from date of injury, if less than 3 years.
  • Copy of Claimant’s Medicare card, if available.

Or send via mail with this completed form to:
Burns White Medicare Compliance Group
Attention: Bruce McKnight
Four Northshore Center
106 Isabella Street
Pittsburgh, PA 15212

Or via email to msaonlinereferral@burnswhite.com

CHECK HERE FOR RUSH SERVICE REQUESTED- 3 BUSINESS DAYS OR LESS

 
Prescription Drug Questionnare for Medicare Set-Asides
Please detail below Claimant’s current work-related prescriptions, dosages, and frequency of use.
Prescription Name 1
Dosage 1
Frequency 1
   
Prescription Name 2
Dosage 2
Frequency 2
   
Prescription Name 3
Dosage 3
Frequency 3
   
Prescription Name 4
Dosage 4
Frequency 4
   
Prescription Name 5
Dosage 5
Frequency 5