Mediare Set-Aside Referral Form
Your name
Your email address *
Referring Company Information
Referring Company
Referring Company Address
Referring Person Information
First Name
Last Name
Phone
Email address
Payor Information
(if different from Referring Company)
Billing Address
Contact person authorizing services
First Name
Last Name
Phone
Email Address
Structured Settlement Broker (if applicable)
Phone
Custodial Administrator (if applicable)
Phone
Client Information
First Name *
Last Name *
Claim # *
Client Address *
Client Phone Number *
SSN *
DOB *      
Diagnosis/Body part accepted in this claim *
State of Workers' Compensation Jurisdiction *
Employer *
DOI *      
(if more than one, please note all dates for settlement)
Attorney Information
- Plaintiff Counsel -
Firm Name
Plaintiff Counsel First Name
Last Name
Phone
Fax
Address
- Defense Counsel -
Firm Name
Defense Counsel First Name
Last Name
Phone
Fax
Address