MSA / MCP / LCP Referral Form INSURANCE CARRIER/TPA/SELF INSURED CONTACT INFORMATION Adjuster Name Phone (###) ### #### Email Adjuster Company Name Claim Number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Carrier Name and Address (if different) CLAIMANT INFORMATION Name First Name Last Name Phone (###) ### #### DOB MM DD YYYY Gender Male Female Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date(s) of Injury / Part(s) of Body SSN Medicare HICN Occupation/Job Duties EMPLOYER/INSURED INFORMATION Employer Employer Name / Title Email Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Phone (###) ### #### SERVICES REQUESTED Worker's Comp MSA Allocation Report Social Security Verification Coordination of Benefits Contractor Notification Conditional Payment Lien Negotiation Allocation Report Revisions CMS Submission of MSA Medical Allocation Report LEGAL REPRESENTATION INFORMATION Defense Attorney Name Defense Attorney Company Name Defense Attorney Address Address 1 Address 2 City State/Province Zip/Postal Code Country Defense Attorney Email Defense Attorney Phone (###) ### #### Applicant Attorney Name Applicant Attorney Company Name Applicant Attorney Address Address 1 Address 2 City State/Province Zip/Postal Code Country Applicant Attorney Email Applicant Attorney Phone (###) ### #### PHYSICIAN INFORMATION Treating Physician Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Thank you!
