Congratulations, you've completed Step 1!

Now you have a few additional items to submit to complete your MSA referral. Please review the checklist below to ensure you submit the proper documentation so that we can immediately start working on your request.

Additional Medicare Set-Aside Submission Forms

If you have not filled out an online MSA referral form, you may download one from below to submit with the other documentation.

For a liability Medicare set-aside, you simply need to submit the MSA Referral Intake Form and all applicable medical records (see description below).

For a workers' compensation Medicare set-aside referral, you must complete and submit (1) the Referral Intake Form (either online or download to fill out and submit), (2) the Proof of Representation, (3) HIPAA Release (4) CMS Consent to Release, and (5) the Social Security Administration Consent for Release of Information.

You must also submit medical documentation. Medical documentation should include pharmacy summary reports, claims payment history or medical bill summary (most recent 2-3 years), second medical opinions and/or agreed medical evaluation (AME) reports. Note: Per CMS guidance, we do not use IMEs, however, if the claim has jurisdiction in CA, we will use and encourage you to submit any applicable AMEs.

If you have a life care plan, please provide a copy of the plan and the 2 most recent years' medical records. If you do not have a life care plan, we prefer all medical record documentation.

Once you've downloaded and completed the applicable forms, return to the Referrals & Forms page to finish your referral at "Step 3: Secure File Upload".

PDF Version

Medicare Set-Aside Referral Instructions
Medicare Set-Aside Referral Intake Form
MSA Releases