Garretson Resolution Group (GRG) looks forward to assisting you with your case.
Click here to view more information about our fees.
We will need the following information to get started on resolving a healthcare lien:
We recommend you complete this form electronically, save, and then email to GRG. This will allow you to fit all relevant information in the form.
Make sure to select applicable “GRG Service Requested”. GRG will only begin work on the healthcare lien/MSA service requested in this column of the GRG Case Intake Form.
CMS Proof of Representation Form OR executed Client Retainer Agreement
To be signed by Beneficiary/Injured Party or Personal Representative and signed by Attorney.
GRG Medicare Law Firm Authority Letter
To be prepared on law firm letterhead and signed by Attorney.
State Specific HIPAA Release Form
To be completed and signed by Beneficiary/Injured Party or Personal Representative.
Florida
Hawaii
Indiana
Louisiana
Massachusetts
New Hampshire
New Jersey
New York
Ohio
Texas
Virginia
Wyoming
GRG HIPAA Release Form (all other states)
To be signed by Beneficiary/Injured Party or Personal Representative.
State Specific Medicaid Letter of Engagement
To be prepared on law firm letterhead and signed by Attorney along with State Specific HIPAA Release or GRG HIPAA Release.
Alabama
California
Ohio
Pennsylvania
South Carolina
Virginia
GRG HIPAA Release Form
To be signed by Beneficiary/Injured Party or Personal Representative. Some Private lien holders may require additional forms to be submitted. These forms, if any, will be provided as soon as they are requested.
Tricare Third Party Liability Form
To be completed by law firm
Tricare Authorization (select a region – North, South or West)
To be completed and signed by Beneficiary/Injured Party or Personal Representative. Please reach out to GRG if you are unsure of region.
North
South
West
VA Authorization
To be completed and signed by Beneficiary/Injured Party or Personal Representative.
VA Questionnaire
To be completed by law firm.
VA POA and Assignment
To be signed by Beneficiary/Injured Party and witnessed by law firm.
GRG HIPAA Release Form
To be signed by Beneficiary/Injured Party or Personal Representative. Some Private lien holders may require additional forms to be submitted. These forms, if any, will be provided as soon as they are requested.
Documents to include:
For faster processing, please name your files to include your firm name, client name, and form name using the following format: FirmName_ClientName_FormName.
For example: ABCLawFirm_JohnQClaimant_GRGIntakeForm.
Please email your completed forms to intake@garretsongroup.com.