Case Submission

Case Submission: Healthcare Lien

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:


 

Step 1: Complete the GRG Case Intake Form


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.


 

Step 2: Complete the Required Claimant Authorizations



Medicare Parts A & B 
(requires two documents)

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.

 

Medicaid (requires one or two documents depending on the state)

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

 

Private Health Plan / ERISA / Medicare Part C (Advantage) / Medicare Supplemental (Medigap) / Hospital & Provider Lien (requires one document)

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 (requires two documents)

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

 

Veterans Affairs (requires three documents)

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.

 

Other Lien Types

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.


 

Step 3: Submit your Case to GRG


Documents to include:

  1. GRG Case Intake Form
  2. Required Client/Claimant Authorization(s)
  3. Additional items to include (if applicable):
      • Prior correspondence with healthcare agency (lien holder)
      • Copy of Complaint (if/when available)
      • Copy of Guardian/Conservator/Estate/Death Certificate documents and/or Power of Attorney
      • PIP/MedPay Exhaust & Payment Ledger (required in all MVA Cases)

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.

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