Secure Online Referral

Please feel free to use this secure page to send referral information and files to us for your MSA or other requested services. We will confirm receipt so that you can be sure that the files and data came through. If you do not hear from us, please feel free to give a call for confirmation at (410) 740-3084 or email us at clientservice@medval.com.

You may also download a Referral Form to fill out. (For client specific files, please click here).

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Required fields are marked with an asterisk (*).

Referral Information














Claimant/Applicant/Plaintiff Information

(numbers only)

(mm/dd/yyyy)

Claimant/Applicant/Plaintiff - Attorney Information

Claim Numbers

(mm/dd/yyyy - separate dates w/ commas)

Employer/Defendant Information

Employer/Defendant: Insurer Information

Employer/Defendant: Attorney Information

Additional Information

$

Documents

Required Documents:

  • For an MSA, we will need the last 2 active years of medical records, the doctor’s first report of injury, and both medical and prescription payment (from PBM if available) histories. If you have any older helpful records (IME/AME/QME reports, Operative Reports, Hospital Discharge Records) please feel free to include those as well.
  • For a Social Security Benefit Verification, we will need the proper release form signed. This release can be downloaded here.
  • For Conditional Payment Resolution, we will need the BCRC release packet signed.





Upload Documents

Please note: You may select multiple files by holding Ctrl (CMD on Apple) and clicking file names. You will need to wait for the selected files to finish uploading before being able to browse for more files.