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).

Please review our Privacy Notice.

Required fields are marked with an asterisk (*).

Referral Information

Referring Party* If Other, please specify:

Name*

Email*

Jurisdiction*

Type of Referral* WorkComp MSA
Non-Threshold WC MSA (NTMSA)
Liability MSA
Update Prior MSA
Social Security Verification
Conditional Payment Resolution
Lien Negotiation/Resolution
Rated Age Request
Pre-MSA Triage Assessment (PTA)
Drug Utilization Assessment (DUA)
Structured Settlement Annuity Quote
Professional Administration Services
Other (Please Specify)
If Other, please specify:

Claimant/Applicant/Plaintiff Information

Name*

Social Security No. (numbers only)

Date of Birth (mm/dd/yyyy)

Address

City

State

Zip Code

Phone Number

Claimant/Applicant/Plaintiff - Attorney Information

Firm Name

Address

City

State

Zip Code

Attorney Name

Email Address

Phone Number

Claim Numbers

Date(s) of Injury (mm/dd/yyyy - separate dates w/ commas)

WCB Claim Numbers

Insurance Claim Numbers

Additional Numbers/Notes

Employer/Defendant Information

Employer Name *

Excess Carrier Policy Number and Underwriting Company Name

Address

City

State

Zip Code

Employer/Defendant: Insurer Information

Insurer Name

Address

City

State

Zip Code

Adjuster Name

Adjuster Email Address

Adjuster Phone Number

Employer/Defendant: Attorney Information

Firm Name

Address

City

State

Zip Code

Attorney Name

Email Address

Phone Number

Additional Information

Estimated Settlement Amount $

Accepted Body Parts

Disputed Body Parts

Special Handling Instructions

Known Settlement Conferences/Hearing Dates

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.

How are you sending us documents?

Through this online form (200MB Max.)
In the Mail (Send to: MEDVAL, 9256 Bendix Rd, Suite 304, Columbia, MD 21045 or MEDVAL, 23046 Avenida De La Carlota, Suite 270, Laguna Hills, CA 92653)
By Email (send to onlinereferral@medval.com)
By Fax (send to 410.740.3088)

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.