HOME ABOUT US OUR SERVICES REQUEST SERVICE CONTACT US MSP COMPLIANCE – ONLINE REFERRAL Referral Date:* MM slash DD slash YYYY Check here if this is a RUSH referral Name:* Address:* Date of Injury:* Date of Birth:* MM slash DD slash YYYY SSN:* Claim Number:* Occupation:* Employer:* Specific Accepted Injuries:* Jurisdiction:* TYPE OF CLAIM – PLEASE CHECK ONE Untitled Workers' Compensation Liability Auto No Fault ACCOUNT INFORMATION Client:* Referred By:* Client Phone Number* Client Email Address* Defense Attorney: Defense Attorney Phone Number Defense Attorney Email Address Claimant Attorney: Claimant Attorney Phone Number Claimant Attorney Email Address SERVICES REQUESTED – CHECK ALL THAT APPLY Services Requested MSA Allocation Report Only (Please include 2 year Payment, Pharmacy, and Indemnity records) CMS Legal Submission Claim Settlement Cost Allocation (Non Threshold Criteria) Medicare Conditional Payment Lien Research (Please include the FROI and Compensable Body Parts) Medicare Conditional Payment Lien Negotiations (Please include the FROI and Compensable Body Parts) Prospective (Pre) MSA Review Drug Utilization Review Post Settlement Professional Fund Administration DOCUMENTS REQUESTED – CHECK ALL THAT APPLY Documents Requested First Report of Injury/Accident AccidentMedical Records for the past 2 years including IME, Diagnostic, Operating Notes, Treatment Summaries, etc Payment Records for the past 2 years including Pharmacy with specific medications Legal and Settlement Documents SETTLEMENT INFORMATION & SPECIAL INSTRUCTIONS SETTLEMENT INFORMATION & SPECIAL INSTRUCTIONS Upload File Drop files here or Select files Accepted file types: jpg, gif, png, pdf, docx, doc, Max. file size: 100 MB. CAPTCHA To learn more about our services, please call (732)-384-3430 © Copyright 2021 Innovative Claims Strategies Privacy Policy Terms of Use