Medical Expense Management Inc.
Liability Referral form
*Note: All fields are required
Account Executive Information (if known)
Name:
Name of Person Entering Referral (if different from above)
Name:
Claim #:
Type of Claim (Please choose one)
  
Nature of Assignment*
Claimant Information
Name*:
Gender:
Address:
City:
State
Zip Code
Phone:
DOB (xx/xx/xxxx):
SSN:
Medicare Beneficiary:
Medicare Number (HICN#):
Social Security Disability Beneficiary:
Account Information (Billing)*
Account Name:
Adjuster*:
Address:
City:
State
State
Phone*:
Email*:
Fax:
Claim Number:
Notes:
Claimant's Attorney
Name:
Address:
City:
State:
Zip:
Phone:
Email:
May MedAllocators contact this person directly?
Claim Information
Proposed Settlement Amount: $
Administration of the LMSA*:
Funding of the MSA:
Preferred Structured Settlement Broker:
Company:
Contact Name:
Phone:
Email:
Fax:
Defense Attorney
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
May we contact this person directly?
Additional Notes: