Make a Referral
Our HIPAA Compliant Referral Form may be used to securely transmit referral information to IMPAXX. We will be in touch to confirm receipt of your submission within 24 hours. If you would like to contact us sooner, please email clientservice@impaxx.com. Please call us at 855.646.7299 should you have any questions.
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Referral Information
Referring Party
Choose One
Adjuster/Examiner
Claims Assistant
Defense Attorney
Claimant/Applicant/Plaintiff Attorney
Medical Consultant
Other (Please Specify in Notes)
If Other, Please Specify
Your Name
*
First Name
Last Name
Company Name
*
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Adjuster Email
example@example.com
Adjuster Name
Adjuster Phone Number
Please enter a valid phone number.
Please Select Type of Case
*
Choose One
Workers' Compensation
Liability
Workers' Compensation with Third Party Liability
Unknown
Is rush service needed?
Yes
No
Requested Due Date
/
Month
/
Day
Year
Based on request date additional fees may apply
Please Select Type of Service(s)
*
All
Conditional Payment and Lien Resolution
MSA, Cost Projection, and Related Services
Post Settlement Administration
CMS Submission
Section 111
Social Security & Medicare Verification
Structured Settlement Services
Other
Please Select Type of Service(s)
*
All
Conditional Payment and Lien Resolution
MSA, Cost Projection, and Related Services
Post Settlement Administration
Section 111
Social Security & Medicare Verification
Structured Settlement Services
Other
If Other, Please Specify
MSA, Cost Projection, and Related Services
*
Medicare Set-Aside (MSA)
Amendment of Another Vendor's MSA
Certified MSA
Medical Cost Projection
Non-Submit MSA (without Certification)
Surgical Cost Projection
Under-Threshold MSA
Rated Age (Without MSA)
Non-Medicare Allowable Items (Without MSA)
Other
MSA, Cost Projection, and Related Services
*
Liability Medicare Set-Aside (LMSA)
Compromise LMSA
Medical Cost Projection
Surgical Cost Projection
Rated Age (Without LMSA)
Non-Medicare Allowable Items (Without LMSA)
Other
Liability Medicare Set-Aside (LMSA) Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
Compromise LMSA Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
Medical Cost Projection Strategy
Settlement Negotiations
Other
Medicare Set-Aside (MSA) Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
Evaluate for Disputed/$0 MSA
Certified MSA Administration
Self-Administration
Professional Administration
Certified MSA Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Non-Submit MSA (without Certification) Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
Evaluate for Disputed/$0 MSA
Is this MSA being requested for Section 111 TPOC reporting?
Yes
No
Unknown
Is the injured worker a current Medicare beneficiary?
Yes
No
Unknown
Will settlement be $25,000 or less?
Yes
No
Unknown
Under-Threshold MSA Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
Amendment of Another Vendor's MSA Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
Evaluate for Disputed/$0 MSA
Medical Cost Projection Strategy
Settlement Negotiations
Setting Reserves
Other
Medical Cost Projection Add Ins
Structure/Annuity Quote through Bridge Pointe
Administration Quote through Bridge Pointe
CMS Submission Services
*
CMS Submission
CMS Amended Review
Conditional Payment and Lien Resolution Services
*
Medicare (Part A/B) Conditional Payment Services
QueryGuard (Medicare Part C/D Identification and Notification)
Medicare Advantage Plan (Part C/D) Lien Resolution Services
US Treasury Recovery
Medicaid Lien Resolution Services
Group Health Lien Resolution Services
Veterans Affairs Lien Resolution Services
Re-Opening of Medicare Liens
Post Settlement Administration Services
*
MSA Professional Administration Services
MSA Self-Administration Support Services
MSA Professional Administration Services Add Ins
Non-Medicare Allowable Items
Structure/Annuity Quote through Bridge Pointe
Section 111 Services
*
Section 111 Reporting
Section 111 Review/Audit
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Claimant/Applicant/Plaintiff Information
Name
*
First Name
Last Name
SSN
This data is encrypted and secured in transmission at all times.
Date of Birth
/
Month
/
Day
Year
State of Jurisdiction
Is this a Specialty Claim with jurisdiction under a Federal Program?
Yes
No
Federal Programs
Longshore and Harbor Workers' Compensation Act (LHWCA)
Defense Base Act (DBA)
Energy Employees Occupational Illness Compensation Program Act (EEOICPA)
Black Lung Benefits Act
Federal Employers' Liability Act (FELA)
Jones Act
Other
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Insurance Carrier Name
Employer Name
Employer Phone Number
Please enter a valid phone number.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claim Number
*
Claim Type
Specific
Continuous Trauma
Date of Injury
/
Month
/
Day
Year
CT Start Date
/
Month
/
Day
Year
CT End Date
/
Month
/
Day
Year
Accepted Body Parts
Denied Body Parts
Please list all body parts or conditions that have been formally disputed or denied and provide Denial Notices (if available).
Additional Claims
Specific
Continuous Trauma
Additional Specific Claims
Additional Continuous Trauma Claims
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Attorney Information
Is the Employer or Insurance Carrier represented by an attorney?
Yes
No
Name
First Name
Last Name
Firm Name
Email
example@example.com
Is the injured party represented by an attorney?
Yes
Yes, but do not contact
No
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Firm Name
Email
example@example.com
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Additional Information
Is there anything else that you would like us to know?
Documents
Required Documents: For an MSA, or MCP Service we will need the last 2 active years of medical records, the First Report of Injury/Notice of Injury, and both medical and prescription payment (from PBM if available) histories. Please also provide Denial Notices (for formally denied body parts/conditions) if available.
How are you sending us documents?
(Recommended) Via this secure online form (up to 200 files per submission, each file up to 500MB in size)
By email (Send To: clientservice@impaxx.com)
By fax (Send To: 407.389.0299)
By mail (Send To: IMPAXX 300 North Beach Street Daytona Beach, FL 32114)
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