Providio MediSolutions provides a broad spectrum of Medicare Secondary Payer Act (MSPA) compliance solutions for law firms, defendant insurers, third party administrators, self-insureds and, of course, Medicare beneficiaries themselves. We are uniquely positioned to provide value to clients by offering a variety of tools to help navigate the uncertain waters of MSPA compliance.
Medicare Set-Aside Forms
For Medicare set-aside referrals, you must complete (1) the Referral Intake Form (either online or download to fill out and submit), (2) the Proof of Representation, (3) the Providio HIPAA Release (4) the CMS Consent to Release, and (5) the Social Security Administration Consent for Release of Information.
Microsoft® Word Version
Medicare Set-Aside Referral Intake Form
Proof of Representation
HIPAA Release
CMS Consent to Release
Social Security Administration Consent for Release of Information
PDF Version
Medicare Set-Aside Referral Intake Form
Proof of Representation
HIPAA Release
CMS Consent to Release
Social Security Administration Consent for Release of Information