LIFE CARE PLANNING REFERRAL

Southern Catastrophic Management Services, Inc.

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CLAIMANT INFORMATION

Claim #:                 Social Security Number:

Claimant Name:

Street Address:     City:     State:     Zip Code:

Phone Number:             Date of Birth:

Date of Accident or Injury:


REFERRAL SOURCE

Carrier/Other:     Email Address:

Street Address:     Suite:

City:     State:     Zip Code:

Billing Information (if different):

Street Address:     Suite:

City:     State:     Zip Code:

Phone Number:     Extension:     Fax Number:

Referring Party / Adjuster:     Date of Referral:


ATTORNEY INFORMATION

Claimant / Plaintiff Firm:   Defense Counsel Firm:
Claimant Counsel:   Defense Counsel:
Street Address:
Suite:
  Street Address:
Suite:
City:   City:
State:      Zip Code:   State:      Zip Code:
Phone Number: Phone Number:
Fax Number:   Fax Number:

EMPLOYER INFORMATION

Employer Name:
Street Address:     City:     State:     Zip Code:
Phone Number:     Extension:


MEDICAL INFORMATION

Injury Related Diagnosis:   

Preexisting Diagnosis:

Other Medical:

Receiving Social Security Benefits?    Yes        No

Medicare Status:     Part A        Part B        None

Are there known Medicare conditional payment claims?    Yes        No

HICN Number: 

Medicaid:

Include signed release for obtaining medical information, if available.


CLAIM STATUS

Has this claim been disputed or controverted?    Yes        No

If yes, details:

Was a life care plan or medical cost projection completed?     Yes        No

If yes, please forward with records.

Mediation scheduled?     Yes        No    If yes, date:

Has a settlement broker been consulted?     Yes        No         If yes, company name:

Phone Number:     Email address:

Custodial account projected?       Yes        No      If yes, name of administrator:

Street Address:     City:     State:     Zip Code:

Phone Number:     Email address:


SERVICES

Completion Medicare Set-Aside:

If yes, complete the following:
        V
erification of SSD /Medicare Status / Liens:
        Medicare conditional payment investigation:
        Releases / Coordination of CMS approval:

Life Expectancy / Rated Age:

Comments:


After submitting form online, mail or fax the following:

Southern Catastrophic Management Services, Inc.
4820 Sawyer Road
Sarasota, FL  34233-2140
Fax: (941) 922-5091
Phone Number: (877) 923-8882

 

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Copyright ? 2004 [Southern Catastrophic Management Services, Inc.]. All rights reserved.
Revised: 12/19/04