Medicare Consultation & Case Management Retention Request

Welcome to our new Retention Request form! We’ve recently upgraded the intake form to be online instead of the PDF form.

Medicare (MSP) Consultation and Case Management Retention Request

Initial Intake Information from Prospective Client

Please fill out the form below to the best of your ability. We will be in touch with you soon after we receive your submission.

Don’t hesitate to contact our offices directly if you have any questions — (805) 879-7555

Your Information
Company*
Excess Carrier (if applicable)
Company Contact*
First Last
Company Contact Email*
Company Contact Phone
Claim Number, if applicable
Date of Loss*
MM slash DD slash YYYY
Accident Location*
Did the accident occur at a retail location?*
- Yes
- No
Retail Store Information*

If incident occurred at a retail location, please provide specific location information such as store title, store number, street names, banners, or other specifying information. Please be specific.
Description of Accident*
Plaintiff/Medicare Beneficiary
Name*
First Middle Last
Sex*
- Male
- Female
- Other / Non-Binary
Is there a loss of consortium claim?*
- Yes
- No
- Unknown
If yes, did the spouse/family member seek medical/mental health treatment?
- Yes
- No
- Unknown
Deceased?*
- Yes
- No
- Unknown
If yes, is the estate pursuing a wrongful death claim?
- Yes
- No
- Unknown
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Date of Birth*
MM slash DD slash YYYY
HICN / SSN (We require at least one of these)*
- HICN
- SSN
- Unknown
HICN*
SSN*
Description of Injuries*
Approximate Medical Specials:
Please include any other Medicare information.
Plaintiff Attorney (if represented at time of assignment)
Is the plaintiff currently represented?*
- Yes
- No
Firm Name*
Attorney Name*
Attorney Email*
Complete Firm Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Firm Phone*
Firm Fax
Defense Attorney (if represented at time of assignment)
Has suit been filed?*
- Yes
- No
- Unknown
Case Number
Court Venue
Are there any Co-Defendants?*
- Yes
- No
- Unknown
Please list Co-Defendants
Please include one co-defendant per line.
Has defense been assigned?*
- Yes
- No
Firm Name*
Attorney Name*
Attorney Email*
Complete Firm Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Firm Phone
Firm Fax
Other Medicare Information
Has COB&R / BCRC been Notified?*
- Yes
- No
- Unknown
Please upload Conditional Payment Letter
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 2 MB.
Please upload Conditional Payment Letter (PDF, JPG, JPEG, or PNG only)
Are you aware of any other statutory insurance coverage, including Medicare Part C, Medicare Part D, Medicaid, ERISA, VA, etc.?*
- Yes
- No
If yes, please explain:
Are you aware of any other liens, including Hospital, UFCW, Attorney, etc.?*
- Yes
- No
We will determine the statutory coverage if it is presently unknown.
Special Instructions/issues
Name
This field is for validation purposes and should be left unchanged.

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