Referrals can be made by mail, fax, email or using the online form below. Forms & Authorizations Mailing Address: MSA Services, LLC 95 Glastonbury Blvd. – Suite 216 Glastonbury, CT 06033-4453 Fax: (860) 657-9838 E-mail: glisowski@msaservicesllc.com Referral Form Injured Party's Name Injured Party's Date of Birth Name of Referring Party or Firm Address of Referring Party or Firm Phone Number E-mail Address Type of Claim ---Workers's CompensationPersonal InjuryLongshoremanUninsured / Under Insured Name of Insurance Company Involved Medicare Status Currently on MedicarePossibly Medicare eligible within 30 monthsNo chance of Medicare eligibility within 30 months Amount of Proposed Settlement (estimate if unknown) Has Liability / Compensability of Claim Been Accepted YesNo Type of Services Requested Analysis of MSA AllocationAnalysis of MSA and Submission to CMSConditional Payment SearchConditional Payment Search & NegotiationSocial Security Offset Proration LanguageFuture Medical Cost Projection Are You Interested In Structuring the MSA YesNo Questions / Special Handling Instructions
