Please fill out the form below regarding your MSA Plus information. You can include attachments at the end of the form.

Your Name (required)

Your Email (required)

Your Company (required)

Your Phone (required)

Type

Claim #:

Services Needed (Select Multiples by holding Control on PC or Command on Mac):

Claimant Name (required)

Claimant Date of Birth (required)

Claimant Social Security Number

Injury Description

Additional Notes:

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 support@jcrmsa.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 support@jcrmsa.com.