New Service Request Form

Submit A Case
Service Information

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 Case & Coverage Notes at the bottom of this page. You may save your progress and come back to this form to complete at a later date.
If you do not receive confirmation of receipt of this form by the offices of Precision Resolution within one hour of submission, please call 888-961-LIEN. Thank you!
Conference Call Requested upon Submission? *

Yes No
Referred By:
Please select at least one service
Medicare Conditional Payment

Medicare Conditional Payment (Parts A/B)
Medicare ID#
Entitlement Date

Month Day Year
Current Lien, if any $
Medicare Advantage Plan

Medicare Advantage Plan
Insurance Co. Name *
Group/ID# *
Current Lien, if any $ *
Medicaid/Public Assitance

Medicaid/Public Assitance
State(s) *
County(ies) *
Current Lien, if any $ *
ERISA or Private Health Plan

ERISA or Private Health Plan
Insurance Co. Name *
Group/ID# *
Current Lien, if any $ *
If Employer-based plan?

Yes No
Specify Employer name *
Please provide Plan Document or Summary Plan Description, if available
TRICARE

TRICARE
Treatment Facilities
Sponsor SSN
Current Lien, if any $
Veteran's Administration

Veteran's Administration
Treatment Facilities
Sponsor SSN
Current Lien, if any $
Liability Medicare Set-Aside Allocation

Liability Medicare Set-Aside Allocation
Workers' Comp Medicare Set-Aside Allocation

Workers' Comp Medicare Set-Aside Allocation
Medicare Set-Aside Submission to CMS

Medicare Set-Aside Submission to CMS
Medicare Set-Aside Opinion Letter

Medicare Set-Aside Opinion Letter
Claimant Information
Name *
Gender *

Female Male
SSN *
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Has claimant lived in another state since date of injury? *

Yes No
What state(s)? *
Does claimant have an Authorized Rep of Power of Attorney? *

Yes No
Name of Authorized Rep or Administrator of Affairs *
Attorney Information
Name *
Phone Number *

Area Code Phone Number
Fax *
Firm *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Attorney Email *
example@example.com
Paralegal/Associate Contact *

Area Code Phone Number
Paralegal/Associate Email *
example@example.com
Primary Case & Injury information
Please choose one option: *

Motor Vehicle Nursing Home Negligence Medical Malpractice Slip & Fall Product Liability Exposure Other
Other *
Date of Injury *

Month Day Year
Date of Death(if applicable)

Month Day Year
Still Treating? *

Yes No
Date of Last Treatment *

Month Day Year
Did Claimaint treat at a hospital? *
Please list names and dates, or submit records with this form:
Specific Nature of Accepted Injuries *
Please submit Complaint, BOP or narrative summary
Does claimant have Pre-Existing Conditions? *

Yes No
Pre-Existing Conditions | Please submit supporting medical records *
No Fault Coverage *

Yes No
*
APIP Coverage *

Yes No
*
Liability Coverage
Has this case settled? Will there be more than one settlement? *

Yes No
Settlement Date *

Month Day Year
Gross Settlement, $ *
Attorney Fee, $ *
Case Expense, $ *
Claimant Net, $ *
Meditation/Arbitration Date *

Month Day Year
Anticipated Settlement, $ *
Anticipated Settlement Date *

Month Day Year
Other Insurance & Special Circumstances

lf the claimant is deceased please forward certificate of death, and letters of administration. lf the plaintiff is a minor, please forward birth certificate or parental affidavit.
Does Claimant have Other Insurance or Special Circumstances?

Yes No
Social Security Disability Insurance

Yes No
Monthly Benefit $
Application Date

Month Day Year
Award Date

Month Day Year
Supplemental Security Income

Yes No
Monthly Benefit $
Application Date

Month Day Year
Award Date

Month Day Year
Other Governmental Benefits

Yes No
Monthly Benefit $
Application Date

Month Day Year
Award Date

Month Day Year
Additional Case & Coverage Notes
Should be Empty:

Submit A Case

Service Information

Please select at least one service

Claimant Information

Attorney Information

Primary Case & Injury information

Other Insurance & Special Circumstances