Case Information Screen Workers' Compensation
Claimant Information
Fields marked with a red asterisk mark (*) are mandatory.
* Last Name

* First Name

* SSN (xxx-xx-xxxx)

* Date of Birth (mm/dd/yyyy)

* Gender

Street Address
City
State
select
Zip
Claimant's Phone Number (xxx.xxx.xxxx)

* Claim Number

* Date of Accident (mm/dd/yyyy)

State of Jurisdiction
select
Employer/Defendant Name

Employer Address

Employer Phone

Employer City

State
select
Zip
 
* Self-Insured

  Required Claim Information
* Carrier

* TPA/Servicing Agent

Excess Carrier
  Contact Information
Who is the referring source?
select
  Please complete all known contact information for the following:
* Adjuster Name

* Phone Number

Fax Number

* Company

Email Address

Adjuster Mailing Address
Address
City
State
select
Zip
Adjuster Physical Address
Address
City
*State
select

Zip
Defense Attorney
Name
Phone Number

Fax Number

Defense Firm
Email Address

Address
City
State
select
Zip
Plaintiff/Claimant Attorney
Name
Phone Number

Fax Number

Plaintiff/Claimant Firm
Email Address

Address
City
State
select
Zip
Structured Settlement Broker
Name
Phone Number

Fax Number

Firm
Email Address

Address
City
State
select
Zip
*Service Requested:- Please call 888.672.7674 with any questions.
 
Social Security Verification Only - Helios Settlement Solutions will determine whether the Claimant/Applicant is a Medicare/Social Security beneficiary. (Requires SS Release)
 
 MSA requested upon verification of SS Benefits?
Medicare Set-Aside Allocation Only** 
       
Rush service available for an additional charge.
Rush needed?
     
 Annuity Quote(if applicable)(rush not available)
     
 MSA Clinical Outreach (if applicable)(rush not available)
Revision
       
 Rush needed?
MSA Clinical Outreach
Future Medical Cost Projection (FMCP) Only**
     
FMCP with MSA
Maryland Future Medical Allocation
Medical Reserve Forecast
CMS Submission
Clinical Cost Containment Review (CCCR)
     
 Case Analysis
 Peer to Peer Outreach
 Clinical Follow up
Conditional Payment Verification
Conditional Payment Analysis
Medication Analysis
     
 Peer to peer outreach?
 Nurse progress monitoring?
Professional Administration
Helios MyMedFund
Assisted Administration
Medicare Advantage Plan Lien Verification
     
Medicare Advantage Plan Lien Analysis
  Notes:
(Please include any information related to this file not otherwise noted.
Maximum 5000 characters are allowed.)
 
   
Pertinent Information Related to the File:
* What diagnoses/body part(s) are accepted in this claim?
   What diagnoses/body part(s) are denied/disputed in this claim?
   What is the proposed settlement amount?
Unless otherwise indicated, the referring party will be responsible for all payments.
**Cancellation of MSA or FMCP after work has commenced is subjected to a fee of $1,300.
If you would like an email confirmation, please enter your email address below. If you would like to send to multiple email addresses, please enter each address separated by a semi-colon. If you have already provided an email address in the Adjuster Contact Information section of this form, you will automatically receive an email confirmation.
Confirmation Email 
Please indicate the Helios Settlement Solutions Associate that worked with you on this file: