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EK HEALTH

Specializing in Workers' Compensation

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EK Health

MSA Referral

MSA Referral

CARRIER

Third Party Administrator

SELF-INSURED EMPLOYER

MSA Data Referral

Client Name*
Claims Adjuster
Phone*
E-mail*
Address
Employer*
Address
Phone
Address

Worker

Injured Worker*
Phone*
DOB
SSN
Address
State of Jurisdiction
Claim(s) #*
WCAB Board and #*
Date of Injury (s)

Conditions

ACCEPTED BODY PART(S) / CONDITION(S)
DENIED BODY PART(S) / CONDITION

ATTORNEYS

Applicant Attorney*
Defense Attorney*
Applicant Attorney Firm Name*
Defense Attorney Firm Name*
Phone*
Phone*
Email
Email
Fax
Fax
Address
Address

SERVICES REQUESTED

Medicare Set-Aside (MSA)

Non-Threshold MSA Allocation (NT-MSA)

Future Medical Allocation (FMA)

Social Security/Medicare Eligibility Verification

Physician Medical Review (Complex cases)

Submission of MSA to CMS

Conditional Payment Investigation

Expedited Referral (completed within 5 business days)

Rated Age Quotation