Additional Medicare Set-Aside Submission Forms
Please download the "Medicare Set-Aside Referral Intake Form" at the bottom of this page in the "Form Downloads" section.
For a Liability Medicare Set-Aide (LMSA), you simply need to submit the MSA Referral Intake Form to email@example.com. Providio will subsequently contact you with a secure link and additional instructions for upload of medical records. If you have a life care plan, please provide a copy of the plan and the 2 most recent years of medical records. If you do not have a life care plan, please provide just the medical records.
For a Workers' Compensation Medicare Set-Aside referral, you must complete and submit (1) the Referral Intake Form, (2) the Proof of Representation, (3) HIPAA Release (4) CMS Consent to Release, and (5) the Social Security Administration Consent for Release of Information. All documents should be sent to firstname.lastname@example.org. Providio will contact you with a secure link for upload of medical records. 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.