Referral Form

Submit your referral and upload the documents after submission.

Referral Form

Claimant/Injured Party Information

Required = *

Claim Information

Defense Attorney Information





Referring Party Information

Plaintiff Attorney Information





Employer/Carrier Information

Services Requested

Allocation Services:

Traditional Workers’ Compensation Medicare Set-Aside (WCMSA)
Liability Medicare Set-Aside (LMSA)
Indemnified Medicare Set-Aside (iMSA)
Indemnified Liability Medicare Set-Aside (iLMSA)
Evidence Based Medicare Set-Aside (eMSA)
Legal Compromise Medicare Set-Aside (LCMSA)
Evaluate for Zero Allocation
Standard Projection
Medical Cost Projection
PreMSA
Rush Request (additional fees apply)
CMS Submission

Conditional Payment Services:

Conditional Payment Verification
Conditional Payment Evaluation
Conditional Payment Dispute/Appeal
Conditional Payment Update
Secure Final Demand/Confirmation of Case Closure
QIC Appeal
ALJ Appeal

Medicare Advantage/Prescription Drug Plan Lien Services:

Verification
Lien Investigation
Lien Evaluation
Lien Negotiation
Secure Final MAP Lien Demand

Medicaid Lien Services:

Lien Investigation
Lien Evaluation
Lien Negotiation
Secure Final Demand

Healthcare Lien Services (TriCare, VA, ERISA, and FEHBA lien, etc):

Lien Investigation
Lien Evaluation
Lien Negotiation
Secure Final Lien Demand

Other Services:










Additional Comments or Special Instructions

Documents Requested for Allocation Services

  • Medical Records including IME/QME/Second Opinion (current 2 years)
  • Prescription History to include drug names and dosage (current 2 years)
  • Payment History Medical and Indemnity Printouts (current 2 years)
  • First Report of Injury with description of injury
  • Proposed Lump Sum Settlement Documents (if applicable)
  • Applicable Legal Documents pertaining to compensability

Once we receive your referral, we’ll be in contact to discuss any additional information that may be necessary. If you have any questions, please contact us at referrals@sandersoncomp.com or call us at 941.479.9877.