Forms

Below you will find many of the ancillary forms needed to complete MSP Services through Franco Signor. Please engage us with any questions you may have at: engage@francosignor.com

 

Manual Referral Forms


Authorizations / Releases

  • SSDI_Disclosure_Release
  • Provides The Social Security Administration with permission to release claimant specific information to a Person or Organization.
  • Consent to Release Form
  • The Medicare Beneficiary has authorized an individual or entity to receive copies of correspondence from the BCRC for a limited period of time. The release does not give the individual or entity the authority to act on behalf of the beneficiary.
  • HIPAA Release Form
  • This form is designed to give authorization for the release of all Protected Health Information, according to HIPPA guidelines.
  • Medicare Beneficiary POR 11.17
  • The Medicare Beneficiary has authorized the individual or entity (including an attorney) to act on the beneficiary’s behalf. The release gives the individual or entity the authority to provide necessary information to or interact with the BCRC (including disputes and appeals), on behalf of the beneficiary, in order to resolve Medicare’s recovery claim.

Additional Forms

  • CMS-Affidavit
  • This provides CMS with claim specific information, in the case there are any delays with the claimant’s primary insurance CMS will make a “conditional payment” so the claimant is not inconvenienced and will be recovered after the primary insurance pays.
  • Final Settlement Detail
  • Provides details to Medicare Secondary Payer Recovery Contractor-NGHP about the final settlement of a claim.
  • Fixed-Percentage-Election
  • This provides a Medicare Beneficiary with an alternative to resolving Medicare’s recovery claim by paying a flat 25% total on liability insurance
  • SSN-HICN-verification
  • This form is to request the proper validation for a Medicare Beneficiary HICN Number assigned by CMS.

 

 

 

 

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