Lien Resolution Group looks forward to working with you on your case.


To get started on your single event lien resolution or MSA allocation, we will need the following information from you. *If you have consolidated actions or mass torts, please do not fill out this intake, but instead go to the contact us page and request a call back or give us a call.

 

1: Complete our Case Intake Form and Required Authorizations for Lien Resolution Or MSA Allocation


This form includes pertinent information on the case. Please be certain to check all requested services you would like us to perform. This also includes required authorizations, which allow us to work with various insurance agencies, including Medicare, Medicaid, and private plans.

Case Intake and Authorizations (PDF)

Please prepare this letter on law firm letterhead and sign by the Attorney

Letter of Authority from Law Firm (PDF)

 

2: Complete the Additional Authorizations, if applicable


For Medicaid Lien Resolution, please also complete the following:

Some states require a state specific HIPAA consent form to be completed. Please have the Beneficiary/Injured (or Personal Representative) complete and sign a state specific HIPAA consent if he/she ever lived in or was treated in the following states (All PDF):

CT, FL, HI, IA, IN, LA, MA, NH, NJ, NY, OH, TX, VA, WY

For TRICARE resolution, a Third Party Liability Form must be prepared by the law firm

Tricare TPL Form

Also, a specific TRICARE form should be completed by the Beneficiary/Injured Party (or Personal Representative) depending on the TRICARE region.  If you are unsure of the TRICARE region please review this map: http://www.mytricare.com/internet/tric/tri/tricare.nsf/dispmap/RegionMap?Open&constituent=Providers

Tricare_NorthTricare_SouthTricare_West

For VETERANS AFFAIRS resolution, authorization should be completed and signed by the Beneficiary/Injured Party (or Personal Representative)

VA Authorization

 

3: Submit your case to us


Please submit all of the requested information to Intake@lienresolutiongroup.com or you may fax the information to 845-638-1237

Once the intake packet has been received and processed by us, the Claims Analyst assigned to your project will reach out to you within 1-2 business days.

If you have any questions regarding the completion of the intake documents, please call us at 1-800-888-1743