MSA Plus Form 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) TypeWorkers' CompensationLiability Claim #: 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 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 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.