Your Name (required)
Your Email (required)
Your Company (required)
Your Phone (required)
Services Needed (Select Multiples by holding Control on PC or Command on Mac):
MSA Allocation ReportLien Investigation or Cost ProjectionProfessional AdministrationSelf-Administration Assistance
Claimant Name (required)
Claimant Date of Birth (required)
Claimant Social Security Number
Upload most recent 2 years of Medical Records
Upload most recent 2 years of Prescription History
Upload most recent 2 years of Claims History
Social Security/Medicare Status Release
In order to verify the Social Security and Medicare eligibility/status of the claimant/applicant, JCR MSA will need a signed copy of the SSA-3288 Social Security Release. Please download this form and have the claimant/applicant sign it. Once signed, email it to email@example.com.
MSPRC Consent to Release
In order to communicate with the Medicare Secondary Payer Recovery Contractor concerning matters regarding the claimant/applicant's injury and settlement, JCR MSA will need a signed copy of the MSPRC Consent to Release Form. Please download this form and have the claimant/applicant sign it. Once signed, email it to firstname.lastname@example.org.