Settlement Document Request

If you are settling a workers' compensation claim you need your settlement documents carefully drafted to not only include the terms and conditions of the settlement but important language that considers the implication of the workers' compensation settlement on important collateral benefits such as Social Security Disability, Supplemental Security Income, Medicare, Medicaid, federal/state cash or medical assistance, short or long term disability benefits or public or private pension plan benefits.

Consideration is also given to any potential offset of Social Security Disability benefits due to receipt of concurrent workers' compensation periodic or lump sum proceeds; Medicare and the need for a Medicare Set-aside whether referred to CMS or not; and Special Needs Trust implications where your client's settlement proceeds may render the client ineligible for Supplemental Security Income or Medicaid benefits.

This service provides tailored drafting of settlement and release documents including important disclosure documents for your client which include the "Informed Consent as to Medical Expenses or Care" and "Notice of Consequences of Your Settlement" forms. These latter two forms provide important plain English disclosure information advising your client of the consequences, obligations and responsibilities which come with the settlement of the claim and how collateral benefits may be impacted.

To request this service please complete and return the Settlement Document Request Worksheet (PDF). Normal turn-around time is 10 business days from receipt of the completed Settlement Document Request Worksheet. The normal charge for preparation of the settlement document and supporting Notice of Consequences of Your Settlement and Medical Informed Consent forms is $975. Once the settlement documents have been released Attorney Sevarino reserves the right to bill for additional revisions. Additional fees for revisions will be discussed in advance of preparation of any revisions.

This fee does not include services for preparation of a Medicare Set-aside, Medicare conditional payment investigation or reconciliation, referral of a submission to The Centers for Medicare & Medicaid Services or to obtain Social Security Administration information. If you need information regarding any of these additional services or fees please refer to the links below.

For additional services and charges see:

  1. Medicare Set-aside analysis MSA Request.
  2. Medicare Conditional Payment Search/Reconciliation MSPRC Request.
  3. CMS Referral Request CMS Request.