Navigating
Connect®

Please call a Service Coordinator for immediate assistance at 1.866.858.7161 (option 2)
or email


 
Quick Referral Form Date of Referral:    
My information
  
     

NuQuest/Bridge Pointe provides the services listed below for both Workers' Compensation and liability cases.


Workers' Compensation Liability Unknown

+
NuShield (Certified MSA)
NuShield (Certified MSA) with non-Medicare allowable items
e-MSA
e-MSA with non-Medicare allowable items
MSA
MSA with non Medicare allowable items (MSAII)
Non-threshold MSA
MCP with Free MSA
Medical Analysis for Bridge Account
Amendment of MSA completed by another vendor
Compromise
Case Consultation
RUSH
+
Submission of MSA to CMS for approval
+
Copy Service
Do you have a preferred date for copy service?
Social Security & Medicare Status Determination
Rated Age only
+
Medicare Self-Reporting Only
Medicare Conditional Payment Investigation
MAO Investigation
Medicare Conditional Payment Claim Negotiation
MAO Negotiation
+
MSA Self-Administration Support Services
1 year
3 year
5 year
Lifetime
MSA Custodial Account Administration
Medical Custodial Account
Medical Reserve Account
Medical Bridge Account
+
NuShield (Certified MSA)
NuShield (Certified MSA) with non-Medicare allowable items
e-MSA
e-MSA with non-Medicare allowable items
Liability MSA
MCP with Free MSA
Medical Analysis for Bridge Account
Amendment of MSA completed by another vendor
Compromise
Case Consultation
RUSH
+
Copy Service
Do you have a preferred date for copy service?
Social Security & Medicare Status Determination
Rated Age only
+
Medicare Self-Reporting Only
Medicare Conditional Payment Investigation
MAO Investigation
Medicare Conditional Payment Claim Negotiation
MAO Negotiation
+
MSA Self-Administration Support Services
1 year
3 year
5 year
Lifetime
MSA Custodial Account Administration
Medical Custodial Account
Medical Reserve Account
Medical Bridge Account
+
NuShield (Certified MSA)
NuShield (Certified MSA) with non-Medicare allowable items
e-MSA
e-MSA with non-Medicare allowable items
MSA
MSA with non Medicare allowable items (MSAII)
Liability MSA
Non-threshold MSA
MCP with Free MSA
Medical Analysis for Bridge Account
Amendment of MSA completed by another vendor
Compromise
Case Consultation
RUSH
+
Submission of MSA to CMS for approval
+
Copy Service
Do you have a preferred date for copy service?
Social Security & Medicare Status Determination
Rated Age only
+
Medicare Self-Reporting Only
Medicare Conditional Payment Investigation
MAO Investigation
Medicare Conditional Payment Claim Negotiation
MAO Negotiation
+
MSA Self-Administration Support Services
1 year
3 year
5 year
Lifetime
MSA Custodial Account Administration
Medical Custodial Account
Medical Reserve Account
Medical Bridge Account
 
 
  
Yes No
Yes No
  
  
     
     
 
 
Name:
Address:
Address 2:
City:   State:    Zip Code:
Email Address:
 
 
Name:
Address:
Address 2:
City:   State:    Zip Code:
Email Address:
 
 
Name:
Address:
Address 2:
City:   State:    Zip Code:
Email Address:
 
 
Yes No
Yes No
Estimated settlement amount: $ Estimated settlement date:
Additional comments:
Yes No
NuQuest recommended by:
Received a marketing call from NuQuest
Received information by mail or email from NuQuest
Attended a conference presentation by NuQuest
Attended a conference where NuQuest exhibited
Other: