Flagship Services Group providing expertise with Medicare Set Asides, Section 111 and Conditional Payments
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Case Type (*Required)
* Case Type:
 
*Description of Injury:  
*State of Jurisdiction:  
Submitter Information (*Required)
*Your Company:  
*Your First Name:   *Your Last Name:  
*Your Email:  
 
*Phone/Ext:  
Claimant Information (*Required)
*Claimant First Name:   Claimant Middle Name:
*Claimant Last Name:   SSN:  
*DOB (MM/DD/YYYY):   Phone:
* Gender:   HICN (if available):
* Medicare Beneficiary?   Date of Incident:
Your Claim Number: Settled Amount:  
Address: City:
State:
Zip:
Plaintiff Attorney' (P.A.) Information:
P.A. Company Name:
P.A. First Name: Last Name:
P.A. Phone: Email:
 
P.A. Address:
City: State: Zip:
Defense Attorney' (D.A.) Information:
D.A. Company Name:
D.A. First Name: Last Name:
D.A. Phone: Email:
 
D.A. Address:
City: State: Zip:
Assignment Notes/ Proposed Settlement (*Required)
Proposed settlement:  
Assignment Notes:  
Supporting Documentation:
Info: Medicare requires medical records dating 2 years prior to the date of last treatment.
Info: A pay ledger including anything paid by insurance carrier. Must have been printed in last 3 months.

Upload any other supporting document related to medical history, comorbidity factors, treatment timeline and/or overall health of claimant.
If individual file is over 150MB, please contact Flagship for instructions at info@flagshipsgi.com after submitting your referral. If you wish to mail your supporting documents, please send them to: Flagship Services Group, 11755 E. Peakview Ave. Suite 250, Englewood, CO 80111.
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