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Name

This field is for validation purposes and should be left unchanged.

Please select all services that apply to your case.(Required)

Medicare Conditional Payment

Medicare Advantage Plan

Medicaid/Public Assistance

ERISA, FEHBA, or Other Private Lien

VA or TRICARE

Medicare Set-Aside Solution

Benefit Preservation & Planning

Plaintiff Structured Settlement

Attorney Fee Deferral

I don't know. Schedule a call.

Precision Resolution will only engage in the services where the corresponding bubble is selected. If other coverage is present, but you do not want us to engage, please enter this info in the 'Additional Coverage & Comments' page at the end of the form.

Following settlement, will the coverage asserting the lien be utilized for the Claimant's future accident-related treatment?(Required)

Yes

Unsure

Please answer to the best of your knowledge, as the response will aid in the formulation of the lien resolution action plan.

Please provide detailed responses so that Precision Resolution can begin formulating an action plan for your case.

Please select an accident type:(Required)

Date of Accident

MM slash DD slash YYYY

Date of Death (if applicable)

MM slash DD slash YYYY

Is the Claimant still treating?(Required)

Yes

Did the Claimant receive treatment at a hospital?(Required)

Yes

Please provide the specific nature of the injuries.(Required)

Please provide a brief accident description.(Required)

Please provide pre-existing conditions or general comments.

Please provide the relevant settlement or anticipated settlement information below.

Has the case settled?

Yes

Date/Anticipated Date of Settlement

MM slash DD slash YYYY

Gross/Anticipated Settlement Amount

Attorney Fee Amount (only if settled)

Case Expense Amount (only if settled)

Have releases been signed?

Yes

Have settlement funds been received?

Yes

General Comments

Please complete the fields below so that Precision Resolution may accurately populate the authorization forms.

Attorney Name(Required)

Attorney Email(Required)

Firm Name(Required)

Firm Phone Number(Required)

Firm Address(Required)

Street Address City State ZIP Code

Please complete the fields below so that Precision Resolution may accurately populate the authorization forms.

Claimant Name(Required)

Claimant Email for DocuSign(Required)

Claimant Date of Birth

MM slash DD slash YYYY

Social Security Number(Required)

Claimant Address

Street Address City State ZIP Code

Please Upload Copies of Insurance Cards, Administration & Authorization Papers, Certificates of Death, Correspondence to Recovery Agencies and Plan Documents. Drag and drop or upload any relevant documentation your office already has on file, including relevant medical records, complaints, etc. All uploads are in compliance with HIPAA regulations.

Select Files

Drop files here or

Max. file size: 10 MB.

Please enter any additional coverage or comments about this case that would be useful for lien resolution engagement.

Before we engage, let's talk through the specifics of the case by way of a Lien Screen Case Consultation. Skip this section if a Lien Screen Case Consultation is not needed.

Date

MM slash DD slash YYYY

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Services

Settlement Planning

Attorney Fee Deferrals

Lien Resolution

Medicare Set Asides

Trust and Asset Management

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