Forms and Releases: Download Page

Please follow this first link if you would like the
Center to evaluate the need for a Medicare Set Aside
and recommend an allocation amount.

Please follow this second link if you would like the
Center to administer a Medicare Set Aside.*

* If you would like the Center to provide both services, please note that you only need to download the forms and releases from the first link. You will only need this one set of forms because the evaluation and recommendation process itself will yield the information needed later for administration of the MSA.

 
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Medicare’s Payments While Claim is Open
Medicare insists, without question or doubt, that any payments it makes for medical services in an open claim are to be reimbursed as part of the settlement of the claim. There is no controversy about this issue. If the parties are settling a claim, they must ensure any Medicare payments for medical services related to the injury are reimbursed as part of the settlement. If you fail to do this, Medicare will pursue reimbursement from any and all sources, including the attorneys. 7-23-01 CMS Memorandum.
When a Reasonable Expectation of Medicare Eligibility Exists
A reasonable expectation of receiving Medicare within 30 months of settlement exists when the injured party: 1) has applied for Social Security Disability (SSD); 2) has been denied SSD but has, or plans to, re-file or appeal; 3) is older than 62 years and 6 months and will therefore turn age 65 within 30 months; or 4) has End Stage Renal Disease.