Rapid Msa Portal

Quickly Generate Accurate Medicare Set-Asides with QuickLiens.

Referral Type

Claimant Name

Claimant SSN

Claimant Date of Birth

Claimant Address

Is the claimant on Medicare now or within 30 months of settlement?

Claimant Medicare ID# (if beneficiary)

Has the claimant applied for, been denied, or is currently receiving Social Security Disability (SSD)?

Has the claimant ever been diagnosed with End-stage Renal Disease (ESRD)?

Date of Injury or First Exposure

State where injury or exposure occurred

Injuries Sustained

Denied Injuries/Conditions (if any)

Provide all actual or proposed settlement defendants/amounts:

Will claimant require ongoing or future treatment for these injuries post-settlement?

If no ongoing/future treatment, what was the last date of treatment?

Does settlement involve a workers compensation claim?

Will any portion of the settlement be allocated toward future medicals?

Requesting Attorney Contact Info

Opposing Attorney/Adjuster Contact Info

Special Notes

Attachments