• Make a Referral

  • Our HIPAA Compliant Referral Form may be used to securely transmit referral information to IMPAXX. We will be in touch to confirm receipt of your submission within 24 hours. If you would like to contact us sooner, please email clientservice@impaxx.com. Please call us at 855.646.7299 should you have any questions.

  • Required fields are marked with an asterisk. Please review our Privacy Notice.

  • Referral Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is rush service needed?
  • Requested Due Date
     / /
  • Please Select Type of Service(s)*
  • Please Select Type of Service(s)*
  • MSA, Cost Projection, and Related Services*

  • Effective July 17, 2025, the Zero MSA does not qualify for submission to the Centers for Medicare & Medicaid Services (CMS) for review.

  • Zero MSA Report Types
  • Has this claim been denied in full and from the outset?
  • Have there been any medical or indemnity payments been made?
  • MSA, Cost Projection, and Related Services*
  • Liability Medicare Set-Aside (LMSA) Add Ins
  • Compromise LMSA Add Ins
  • Medicare Set-Aside (MSA) Add Ins
  • Certified MSA Administration
  • Certified MSA Add Ins
  • Non-Submit MSA (without Certification) Add Ins
  • Is this MSA being requested for Section 111 TPOC reporting?
  • Is the injured worker a current Medicare beneficiary?
  • Will settlement be $25,000 or less?
  • Under-Threshold MSA Add Ins
  • Amendment of Another Vendor's MSA Add Ins
  • Medical Cost Projection Strategy
  • Medical Cost Projection Add Ins
  • CMS Submission Services*
  • Conditional Payment and Lien Resolution Services*
  • Post Settlement Administration Services*
  • MSA Professional Administration Services Add Ins
  • Section 111 Services*

  • Claimant/Applicant/Plaintiff Information

  • Date of Birth
     / /
  • State of Jurisdiction
  • Is this a Specialty Claim with jurisdiction under a Federal Program?
  • Federal Programs
  • Format: (000) 000-0000.
  • Claim Type
  • Date of Injury
     / /
  • CT Start Date
     / /
  • CT End Date
     / /
  • Additional Claims
  • Additional Specific Claims
  • Additional Continuous Trauma Claims

  • Attorney Information

  • Is the Employer or Insurance Carrier represented by an attorney?
  • Is the injured party represented by an attorney?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Additional Information

  • Required Documents (MSA & MCP Services)
    Please upload the following to help us process your referral as quickly as possible:

    • Medical Records (Full 24 months of injury-related medical records)
      • If there are gaps in treatment, count back 24 months from the last date of active treatment
      • Include records for each claimed injury/body part
      • Include Utilization Review (UR), Independent Medical Review (IMR) decisions, and/or Independent Medical-Legal Exams (if applicable)
    • First Report of Injury (FROI) or Notice of Injury
    • Claims Payment History (for every claim being settled)
      • Medical
      • Indemnity
      • Expense (if applicable; recommended if submitting to CMS)
    • Prescription (Pharmacy) History (for each claim)
      • Include drug name, dosage, and quantity dispensed
      • PBM records preferred (if available)
    • Denial Notices (if applicable)
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