Online Referral Form

Type of Case Workers' Compensation
Liability
Longshore
No-fault
Other
Service Being Requested Medicare claim/lien research
MSA allocation report
RUSH allocation report - additional fee
Life Care Plan
SSD/Medicare verification
Claim Information
*Claimant First Name
Claimant Middle Initial
*Claimant Last Name
*Date of Birth
*Social Security Number
*Claimant Address
*Claimant City
*Claimant State
*Claimant Zip Code
*Claim Number
Claimant's Attorney (if represented) Name

Address

Telephone Number

Email Address
Additional Information

Is the claimant a current Medicare beneficiary?  

Is the claimant currently entitled to Social Security Disability?  

Is it permissible to contact the claimant and/or attorney to obtain a signed authorization?  

Defendant Information
*Defendant/Insured
Name Defendant/Insured Address
*Date of Injury
*State of Jurisdiction
Referring Party
Name

Referring Party Company Name

Address

Telephone Number

Email Address
If TPA, please indicate underlying insurance carrier or self-insured
Company Name
Representative Name
Address
Telephone
Email Address
Local Defense Attorney Name

Address

Telephone Number

Email Address
Preferred Structured Broker Name

Address

Telephone Number

Email Address
Additional Information Is liability in this case disputed?
Please list all accepted injuries:
Please list all disputed/denied injuries:
Tentative Settlement Has a tentative settlement agreement been reached?
If yes, indicate settlement amount
Finalized Settlement Agreement Has a settlement agreement been finalized?
If yes, indicate finalized settlement amount
Negotiations If no agreement yet, are negotiations underway?
Estimated settlement range?
Pending Dates Please list pending mediation, trial or other court dates:
Additional Notes

  • Please provide the following documentation (not necessary for claim/lien research or SSD/Medicare verification only):
  • Medical and prescription records from the most recent two years of treatment (if not available, please note why)
  • Current claims payment history, including medications
  • Draft or final settlement documents/Release, if available
  • First Report of Injury for workers' compensation cases

    For a printable version of the referral form, click here.

    To upload documents directly using our secure website please click on the following link:

    https://securefiles.carrallison.com/a/wreq/6kz08888mykpxfj7HHW7lYCSHPSVPrNL

    Thank you very much for your referral! If sending documents via hard copy, please mail them to the following address:

    Carr Allison
    Medicare Compliance Group
    Attn: Melisa Zwilling, Esq.
    100 Vestavia Parkway
    Birmingham, AL 35216

    *required