Lien Resolution Intake Form

Name

SSN

Gender: Male Female

Date of Birth

Address

City

State

Zip

Phone

If dependent, please identify contact:
Name

Relationship

Phone

Insurance Information

Medicare #

Medicare ID

Sponsor #

Insurer

Policy #

Employer

Case Information

Date of Loss

Injury

Description of Incident

Liability Insurer/ Defense Attorney/ Defendant

Policy Number

Phone

Defense Attorney

Attorney Name

Firm Name

Address

City

State

Zip

Phone

Fax

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