Referred By:	Claimant/Plaintiff Information:	
Name:  	Name:  	
Title:   	Address:  	
Company:  	City:  	
Address	State:  	
City:  	Zip:  	
State	Phone:  	
Zip:  	Date of Birth:  	
Phone:  	SSN: 
Medicare Number:                              
Medicare Entitlement Date: 	
Fax:  	Date of Injury:  	
E-Mail:                          	Claim #:  	
Date of Referral	Claim Jurisdiction: 	
Employer Information (WC Only):	Line of Insurance:   WC    Liability   No- Fault	
Name:  	Applicant Attorney	
Address: 	Name:  	
City:	Address:  	
State:	City:   	
Zip:  	State:             Zip:  	
	Phone:                    Email:	
SERVICE REQUESTED
                Conditional Payment Search/Analysis 
                Conditional Payment Dispute/Appeal
                U.S. Department of Treasury Appeal
   Conditional Payment Refund
	Defense Attorney
Name:  
Address:  
City:                                  State                          Zip:
Phone:
Email:	
What are the injuries/ ICD codes that were reported to Medicare?

Who is/are the approved provider(s) on the claim?

Does Claimant/Plaintiff have benefits through a Medicare Advantage Plan?  If Yes, please provide plan name and contact information:

	Has the case settled?  

Date case settled:

If case has settled please provide a copy of the Settlement Agreement	
Do you believe that the charges indicated by Medicare on the Statement of Reimbursement are incorrect?  If so please explain why: 

	Are you able to provide any medical reports or other documentation that correspond to any of the charges listed on the Statement of Reimbursement?

Do you require assistance in obtaining documentation to demonstrate that the Medicare ‘s charges are incorrect?               	
Special Instructions for file handling:  

	Other Considerations: