Medical Cost Services – TrustTOSS

MEDICAL COST SERVICES

RUSH
Rush*
- Medical Cost Projection (MCP)
- Medicare Set Aside (MSA)
- Conditional Payment Search
- MSA CMS Submission
- Dispute/Appeal Search
- Medicaid/Medicare AdvantageLien
Social Security/Medicare Verification
Claim Information
Claim #*
Date of Injury:*
MM slash DD slash YYYY
Compensable Body Part (s):*
Denied Condition (s):*
Employer Information
Employer:*
Phone #*
Address:*
Carrier Information
Carrier:*
Adjuster:*
Address:*
Adjuster Phone#*
Adjuster Email:*
Claimant Information
Claimant Name:*
Claimant SSN#*
Claimant Address:*
Claimant Date of Birth:*
MM slash DD slash YYYY
Claimant Phone#*
Special Instructions
Special Instructions

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