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

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