SECTION 2: MEDICARE SET-ASIDE INFORMATION
MEDICARE CONDITIONAL PAYMENT & SET-ASIDE INTAKE FORM MSA ALLOCATION PROPOSAL & SUMMARY MSA SUBMISSION DATE OF REQUEST: So that Precision may begin processing your file immediately, please submit this completed form along with the following documents to [email protected]: Executed CMS Proof of Representation Form Precision Resolution, LLC Proof of Representation Language copied onto your firm’s letterhead and executed by the retaining attorney MOTOR VEHICLE ACCIDENT: NO-FAULT CARRIER FULL & PROPER NAME: CARRIER ADDRESS POLICY # CLAIM # MIGHT APIP BE OBLIGATED TO PAY MEDICALS? IF YES, APIP CARRIER FULL & PROPER NAME: CARRIER ADDRESS POLICY # CLAIM # EXPOSURE SLIP & FALL : NURSING HOME NEGLIGENCE PRODUCT LIABILITY OTHER: LIABILITY CARRIER FULL & PROPER NAME: CARRIER ADDRESS IF YES: PART A PART B MEDICARE ENTITLEMENT DATE PART C PART D POLICY # CLAIM # IS THERE A WORKERS’ COMPENSATION CLAIM? WORKERS’ COMPENSATION CARRIER FULL & PROPER NAME: CARRIER ADDRESS POLICY # CLAIM # SECTION 2: MEDICARE SET-ASIDE INFORMATION PLEASE EMAIL THE FOLLOWING DOCUMENTS (IF READILY AVAILABLE) PROOF P OF REPRESEN NTATION The u undersigned Medicare beneficiary b in nforms the Centers C for Medicare & Medicaid S Services (CMS) that they have g given the sp pecified lega al representa ative the autthority to rep present them m and act on n their behalf with respe ect to anyy claims for liability insu urance, no-fa ault insuranc ce, or worke ers compenssation, including releasing identifiab ble health h information n or resolvin ng any pote ential recove ery claim th hat Medicare e may have e if there is a settlement, judgm ment, award,, or other payment. p Th he undersig gned repressentative ag rees that th hey represe ent the stated Mediccare beneficiary. e of Represe entative: Type Authorized d Representtative: ( ) Individual other o than an n Attorney: ( X ) Attorney ( ) Guardian* ( ) Conservato or* ( ) Power of Atttorney* __________ __________ __________ ___________ _________ (Attorney/ L Law Firm Na me) __________ __________ __________ ___________ _________ (Law Firm A Address) __________ __________ __________ ___________ _________ (Law Firm C City, State, Z Zip) __________ __________ __________ ___________ _________ (Phone Nu mber) * If the e beneficiary is s incapacitate ed, his/her gu uardian, conse ervator, powe er of attorney etc. will need d to submit docum mentation in ad ddition to this s proof of reprresentation. Medic care Benefic ciary Inform mation: Benefficiary’s Nam me (pleas se print exa actly as sho own on yourr Medicare card): c _ _________ ___________ __________ ______ Benefficiary’s Health Insurance Claim Num mber (numb ber on Medicare card):: _ _________ ___________ __________ ______ Date o of Illness/Inju ury for whic ch the benefficiary has filed a liabilitty insuranc ce, no-fault insurance or o workers’ comp pensation cllaim: _ __________ ___________ __________ ______ Benefficiary’s Sign nature: ____ ___________ __________ ___________ ___ Date ssigned: ____ ___________ _______ Repre esentative’s Signature: ___________ _ __________ __________ ___ Date ssigned: ____ ___________ _______ GFRG-2010 Medicare Secondary Payer Recovery Contractor MSPRC-NGHP Post Office Box 138832 Oklahoma City, OK 73113 PRECISION RESOLUTION, LLC PROOF OF REPRESENTATION RE: Beneficiary: HIC#: Date of Incident: Dear Sir or Madam: Please be advised that , the attorney for the above referenced Medicare beneficiary, has appointed Precision Resolution, LLC as representative regarding the resolution of any Medicare conditional payment issues pertaining to this file. Please provide Precision Resolution, LLC with any information regarding this claim to the following address: Precision Resolution, LLC 3686 Seneca Street Buffalo, NY 14224 Signature of Beneficiary’s Attorney: __________________________________________ Date: Representative’s Signature: _______________________________________ Paul R. Loudenslager, Esq. Precision Resolution, LLC Date:
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