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Case Referrals

Please complete our online referral form or download the documents and fax or mail back to us.

Forms for Download
Lien Resolution Intake Form
HIPAA Authorization Form
LSS/Medicare Proof of Representation Form

Lien Resolution Intake Form

Male Female


If dependent, please identify contact:

Insurance Information

Case Information

Defense Attorney

Services Requested

Verification Only      Lien Resolution     Plan Evaluation     Medicare Set Aside    
Other

Insurance Type

Medicare      Medicaid - State Plan     Military (VA/TRICARE)     ERISA / Private Health    
Other


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