GRMedicare Referral Form

Online Referral Form

*Denotes required information.

Rush Service Request

3 BUSINESS DAYS OR LESS
1 BUSINESS DAYS OR LESS

Service Being Requested

Medicare Conditional Payment Search
MSA
Medical Cost Projection
Medicare Eligibility Verification
Medicaid Conditional Payment Search
Settlement Cost Projection
Section 111 Medical Cost Projection

Case Classification

WC
Liability
No-Fault
Longshore
Jones Act

Adjuster Information

Referring Party Name
Referring Party Address *
Referring Party Address Line 2
City

State / Province / Region
Postal / Zip Code

Country
Referring Party Phone *
Referring Party Email *
Preferred Structure Settlement Broker

Referring Party Information

Claimant Name *
Date of Injury *

Claim Number
Claimant Address
Claimant Address Line 2
City

State/Providence/Region
Jurisdiction

Postal / Zip Code
Claimant Social Security Number *

Claimant Date of Birth *
Claimant Employer
Claimant Employer Address
Claimant Employer Phone Number
Defense Counsel's Contact Information
Claimant's Counsel's Contact Information

Claimant Case Information

How did injury occur?
Are there any denied conditions? Yes
No
List of denied conditions
What are the accepted body parts?
Please give title and brief description of the Claimants job at the time of injury.
Is Claimant currently receiving Social Security Disability benefits? Yes
No
Is Claimant currently eligible to receive Medicare benefits? Yes
No
What is the total amount of indemnity benefits paid to date?
Has a settlement been reached? Yes
No
Please provide the estimated medical settlement amount.
Tentative Settlement Range
How is set aside to be paid? Out of settlement proceeds
Above and beyond settlement proceeds

Documentation Checklist

Please upload the following copies with this completed form:

Records/reports from Claimant’s treating physician or physicians from the last two (2) years of treatment.
Print out of full payment history and full RX history
Copy of Claimant’s Medicare card, if available
Copy of any prior rated ages, if available
Relevant legal documents, if available

Click here to choose a file and upload attachments.

Uploaded Attachments

Any files you have attached will show up here. There is a limit of 40 megabytes for each uploaded file.