.. Loading ..

Call Us: (866) 306-9423
Our Address: 47 Waterbury Road - Suite 357, Prospect, CT 06712

Forms & Authorizations

Home
Forms & Authorizations

Documentation Needed To Complete The MSA

Copy of the proposed settlement agreement (if available)
Treatment records (last two years of treatment)
Prescription drug history from pharmacy (last two years)
Payment history from insurance company (last two years)
Signed Consent to Release
Completed Referral Form

Printable Forms

1. Referral Form – WC MSA
2. Referral Form – Liability MSA
3. Referral Form – Settlement Language
4. Referral Form – Conditional Payments
5. Proof of Representation
6. Consent to Release