Claimant Name:

Claim #:

Claimant Address:

City:

State:

Zip:

Claimant Phone Number:

Claimant Email:

County:

Diagnosis related to this claim:

State of Jurisdiction:

DOI:

SSN:

DOB:

Referring Company:

Date of Referral:

Referring Individual:

Referring Company Address:

City:

State:

Zip:

Payer information

Payer Company:

Billing Address:

Contact person:

Phone/Ext:

Email:

Attorney Information

Plaintiff Counsel Name:

Phone:

Fax:

Email:

Plaintiff Counsel Address:

City:

Defense Counsel Name:

Phone:

Fax:

Email:

Defense Counsel Address:

City:

State:

Zip:

Referral Checklist
Please forward the following:

( ) Printed medical payout history for last 3-5 years
( ) Medical records for past 3-5 years from all providers
( ) Copy of proposed state workers' compensation settlement documents
( ) Copy of all pleadings (Complaint, Answer, Motions, etc.)

Capehart & Scatchard, P.A.
Laurel Corporate Center
8000 Midlantic Drive
Suite 300
Mount Laurel, New Jersey 08054
856.234.6800
Fax 856.235.2786
www.capehart.com

Please complete the following questionnaire:

1. Has a settlement agreement been reached?: Yes No

   If yes, list:

   Date of Settlement:
   

   Amount $:
   

   Please breakdown total below:

   Medical $:
   

   Indemnity $:
   

   Attorney Fees $:
   

   
   

   If no, list:

   What is the approximate settlement value:
   

   Is mediation scheduled?: Yes No

   Date of mediation:
   

2. Is a structured settlement broker involved in this settlement?: Yes No

   If yes, list:

   Brokers name/company:
   

   Phone Number:
   

3. Is a custodial account being used in this settlement?: Yes No

   If yes, list:

   Custodians name/company:
   

   Phone Number:
   

   If no, list:

   Is the claimant mentally capable of self-administration?: Yes No

4. Is claimant currently receiving Medicare benefits?: Yes No

   If yes, list:

   Medicare number (if known):
   

   Date of Medicare entitlement (if known):
   

5. Are there any Medicare liens you are aware of?: Yes No

   If yes, list:

   Provide details:
   

6. Is claimant currently receiving SSD benefits?: Yes No

   If yes, list:

   Date and reason for entitlement:
   

7. Is claimant currently receiving SS Retirement benefits?: Yes No

   If yes, list:

   Date of entitlement:
   

8. Is the claimant currently receiving SSI (supplemental security income)?: Yes No

   Is the claimant currently receiving Medicaid benefits?: Yes No

9. Is claimant currently working?: Yes No

10. Is this or any portion of this claim denied or disputed?: Yes No

    If yes, list:

    Provide details:
    

    Is there a legal or medical opinion supporting the denial or dispute?: Yes No

11. List any known condition(s) not related to the WC injury:
    

12. List, and provide known detail, if claimant is receiving:

    1. Medicare HMO Benefits?:
       
    2. VA benefits?:
       
    3. Government benefits or has a child receiving government benefits?: