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

  • LOA - Blank
  • Letter of Agency, Proof of Representation Agent Agreement
  • SSDI_Disclosure_Release
  • Provides The Social Security Administration with permission to release claimant specific information to a Person or Organization.
  • CONSENT-TO-RELEASE-Fillable-Form
  • Gives permission to the specific party to obtain identifiable medical information related to the claimant liability claim.
  • 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 11-2017
  • Is an individual that is entitled to benefits under the Medicare part A.

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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