Burns White Medicare Group

Online Referral

	* 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