Forms

Fee Schedule

Medicare Set-Aside Referrals:

Electronic Medicare Set-Aside Submission Form

Complete this form online to obtain an MSA analysis. This form allows you to upload file attachments (payment history, rated age, and medical records) as well as mandatory case information.

Manual Medicare Set-Aside Submission Form

Complete this form to obtain an MSA analysis. Mail or e-mail the completed form and specified documentation to address at the top of the form. (Use the Word form to enter information by typing, or use the PDF form to fill out by hand.)

 

Custodial Administration Referrals:

MSA/MCA Custodial Submission Form

Complete this form to obtain custodial services by Protocols, LLC for a Medicare Set-aside Account or Medical Custodial Account.  Mail or e-mail the completed form and specified documentation to address at the top of the form. (Use the Word form to enter information by typing, or use the PDF form to fill out by hand.)

View the Fee Schedule for our Administration Services here.