Referrals must be submitted with the following information:
- 3-5 years prior medical history
- 2 years prior prescriptions
- 3-5 years prior medical payout screens
- Copy of Medicare/Social Security card
- Signed Medicare and Social Security releases
- Proposed settlement documentation
(mandatory for CMS approval)
Please submit all documentation to:
Specialty Allocations, Inc
555 Winderley Place Suite 300
Maitland, Florida 32751
| |
Click on the links below to download PDF versions of each form.
MEDICARE CONSENT TO RELEASE FORM
SOCIAL SECURITY ADMINISTRATION RELEASE FORM
SPECIALTY ALLOCATIONS MEDICAL RELEASE FORM
REFERRAL INSTRUCTIONS:
Referrals must be submitted with the following information:
- 3-5 years prior medical history
- 2 years prior prescriptions
- 3-5 years prior medical payout screens
- Copy of Medicare/Social Security card
- Signed Medicare and Social Security releases
- Proposed settlement documentation (mandatory for CMS approval)
Please submit all documentation to:
Specialty Allocations, Inc
555 Winderley Place Suite 300
Maitland, Florida 32751
| |
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