Secure Online Referral

Referring Party* Adjuster/Examiner Defense Attorney Claimaint/Applicant/Plaintiff Attorney Medical Consultant Other (Please Specify) If Other, please specify:

Name*

Email*

Jurisdiction*

Type of Referral* Workers’ Compensation MSA (WCMSA)
Non-Submit/Evidence Based Medicine MSA
Liability MSA (LMSA)
No-Fault MSA (NFMSA)
Non-Threshold WC MSA (NTMSA)
Future Medical Cost Projection (FMCP)
Update Prior MSA
Amended Review of CMS Opinion
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:

Name*

Social Security No. (numbers only)
(This data is encrypted and secured in transmission at all times.)

Date of Birth (mm/dd/yyyy)

Address

City

State

Zip Code

Phone Number

Firm Name

Address

City

State

Zip Code

Attorney Name

Email Address

Phone Number

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

WCB Claim Numbers

Insurance Claim Numbers

Additional Numbers/Notes

Employer Name *

Excess Carrier Policy Number and Underwriting Company Name

Address

City

State

Zip Code

Insurer Name

Address

City

State

Zip Code

Adjuster Name

Adjuster Email Address

Adjuster Phone Number

Firm Name

Address

City

State

Zip Code

Attorney Name

Email Address

Phone Number

Estimated Settlement Amount $

Accepted Body Parts

Disputed Body Parts

Special Handling Instructions

Known Settlement Conferences/Hearing Dates

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?

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