Forms

On this page you will find the most commonly used authorization and release forms for Franco Signor to provide complete MSP services to you. If you have any questions, please contact us at engage@francosignor.com.

Manual Referral Form

This form is a downloadable version of our online referral form for the submission of a
referral to Franco Signor.

Authorizations/Releases

Provides the Social Security Administration with permission to release claimant-specific information to a Person or Organization.

The Medicare Beneficiary has authorized an individual or entity to receive copies of correspondence from the BCRC for a limited period of time. The release does not give the individual or entity the authority to act on behalf of the beneficiary.

This form is designed to give authorization for the release of all Protected Health Information, according to HIPAA guidelines.

The Medicare Beneficiary has authorized the individual or entity (including an attorney) to act on the beneficiary’s behalf. The release gives the individual or entity the authority to provide necessary information to or interact with the BCRC (including disputes and appeals), on behalf of the beneficiary, in in order to resolve Medicare’s recovery claim.

Miscellaneous Forms

This provides a Medicare Beneficiary with an alternative to resolving Medicare’s recovery claim by paying a flat 25% total on liability insurance.

Request for the claimant to provide their SSN and/or MBI or certify they are not receiving Medicare benefits.