Management Services, Inc.
Social Security Number:
Date of Birth:
Date of Accident or Injury:
Billing Information (if
Referring Party /
Date of Referral:
Injury Related Diagnosis:
Receiving Social Security Benefits?
Are there known Medicare conditional payment claims?
Include signed release
for obtaining medical information, if available.
Has this claim been disputed or controverted?
If yes, details:
Was a life care plan or medical cost projection completed?
If yes, please forward with records.
No If yes, date:
Has a settlement broker been consulted?
No If yes, company name:
Custodial account projected?
No If yes, name of administrator:
If yes, complete the
Verification of SSD
/Medicare Status / Liens:
Medicare conditional payment investigation:
Releases / Coordination
of CMS approval:
Life Expectancy / Rated
After submitting form online, mail or fax the following:
Medical records, including hospital
Printed medical claims payment history
Notice of injury and records
for initial treatment
Medication and DME printouts (if available)
Signed releases authorizing
communication with physicians, etc. (if available)
Rated age on life company
letterhead (if completed)
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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