Claimant Information
* Claim Number:   * Date of Injury:  
* Claimant First Name:   * Claimant DOB:  
* Claimant Last Name:   * Gender: 
* Claimant SSN:   * Plan Type: 
* Jurisdiction: 
* Employer/Customer Name:  
 
* Case Handler Name:   
* Case Handler E-Mail:    
* GRS or Legacy RCG Name:  
* Claim ID:   
* Segmentation Type:  
* Referring Party Name:  
 
* Services Requested:  Conditional Payment Services
 Medicare Set-Aside Services

MSP Legal Services
Other Services
 
Additional Referral Questions
Accepted ICD 9/10 Codes/Body Parts:
 
Denied ICD 9/10 Codes/Body Parts:
Reason for Denial:
* Class of Beneficiary:
Additional Comments: