MSA Release Forms

The following release forms are required for Allsup to obtain information regarding the claimant's Medicare entitlement status and Medicare conditional payments, if applicable, and for submission of the Medicare Set-aside Arrangement (MSA) to the Centers for Medicare & Medicaid Services (CMS) if it is determined that CMS approval is needed once a settlement has been reached.

Form SSA-3288 – Social Security Administration (SSA) form that allows Allsup to gather Medicare entitlement information and Social Security Disability Insurance (SSDI) filing information. Please note, although a possible charge is indicated, there will be NO charge for obtaining the requested information from the SSA.

Authorization to Communicate with Medicare – Centers for Medicare & Medicaid Services (CMS) form that allows Allsup to communicate with CMS.

CMS Consent to Release – HIPAA form that is submitted if The Centers for Medicare & Medicaid Services (CMS) needs to be contacted in regards to the workers’ compensation claim.

Allsup Authorization For Release of Information – Allsup’s form that allows Allsup to release claim status to a third party.