Submit a Referral

You may use this page to request a Medicare Set-aside (MSA) or other related services. Someone from J29 will confirm receipt of the referral. You can also call us at (866) 529-6771 to refer a case over the phone or e-mail us at referrals@J29inc.com and someone will get back with you immediately.

Please note, information noted with an * is required.

Referral Info

Referral Source

Referral Source E-mail

Referral Source Phone

Service Requested

Service(s) Requested

Special Instructions

Claimant / Plaintiff Information

First Name

Last Name

Date of Birth

Claimant Plaintiff SSN

Address Line 1

Address Line 2

City

State

Zip Code

Claimant Attorney Information

First Name

Last Name

Phone

Firm Name

Address Line 1

Address Line 2

City

State

Zip Code

Adjuster | Carrier | Employer / Insured | TPA | Defense Attorney

Adjuster / Claim Handler First Name

Adjuster / Claim Handler Last Name

Adjuster / Claim Handler Email

Adjuster / Claim Handler Phone

Insurance Carrier Name (if applicable)

Employer / Insured Name

Third-Party Administrator (TPA) Name (if applicable)

Defense Attorney Info

First Name

Last Name

E-Mail

Phone

Firm Name

Address Line 1

Address Line 2

City

State

Zip Code

Claim Information

Insurance Type

Claim Number(s)

Date(s) of Incident

Work Comp Board # (if applicable)

Accepted Body Part(s) / Condition(s)

Denied Body Part(s) / Condition(s)

Attach a file

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For a Medicare Set Aside, we will require the following:

Last / Latest 2 years of medical treatment records for all injuries / conditions
Last / Latest 2 years of medical payment & prescription drug payment histories
Last / Latest 2 years of indemnity / expense records
First Report of Injury
Any court orders or rulings
Medical evaluations (IMRs, IMEs, AMEs, QMEs, etc.)

You can also send documents:

Via e-mail: referrals@j29inc.com
Via Fax: (866) 695-9904
Mail: J29, Inc. 1111 Benfield Blvd., Suite 114
Millersville, MD 21108