To help expedite the process, we provide you with the following referral forms that you can complete and submit. When you submit your referral, please make sure you have all checklist items. Any missing items could delay the process, especially when working with anything requiring submission to the Centers for Medicare and Medicaid Services (CMS). It is to your benefit to make sure that all checklist items that accompany the referral forms.
If you are requesting a Conditional Lien Verification, you must complete a form for each date of loss/claim individually (they may not combined and be done on a single form). You can combine for a Medicare Set-Aside Allocation itself, but not for the conditional lien verification.
If you are requesting a Workers’ Compensation or Longshore Act Medicare Set-Aside:
If you are requesting a Liability or Maritime Jones Act Medicare Set-Aside:
The following Consent forms are used for both Workers’ Compensation/Longshore and Liability/Jones:
- Consent to Release
- CMS Affidavit (allows only one directional communication with CMS)
- Letter of Agency – POR Agent Agreement (allows 2-way communication with CMS)
- SSN-HICN verification
- SSA-3288 Consent for Release Form
- Lien Representation Agreement
- HIPAA-Release-Form 041916