Case Intake Form
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1Case Intake Form
Date ___________________
Phone 704.559.4300
Claimant Information
Plaintiff
Party Representing ____________________________________________
N
_____ ____________________
_____
Your Case Number / Reference Code ______________________________
Phone ________________________ Fax _________________________
Name ________________________ Gender ________________________
Male
_____________________________________________
SSN _____________________ DOB _______________________________
Address _
__________________________________________
Address _____________________________________________________
City _______________ State _____________ Zip ___________________
Email _______________________________________
City _______________ State _____________ Zip ____________________
Phone ______________________________________________________
Has claimant lived in another state since date of injury?
Yes*
No
Case Type (please check all that apply)
*If yes, what state? _____________________
Motor Vehicle Accident
No Fault Policy?
Yes
No
Email (optional) ______________________________________________
Medical Malpractice
Injury Information
Workers’ Compensation
DOI* __________________ DOD* (if applicable) _____________
Please Specify ___________
*Date of accident/date of exposure/date of ingestion/date of injury
Please Specify ___________
Actual / Projected Date of Completed Treatment ___________________
Product Liability
Please Specify ___________
Other
Injuries Sustained
Applicable Claims/Actions (please check all that apply)
Pre-Existing
Wrongful Death
State Filed _______
Court Allocated?
Yes
No
Conditions
Derivative (Loss of consortium, etc.)
Survivor
Injury-Related Medical Expenses (to date)
$______________
Is injury-related care anticipated post-settlement?
Yes
No
Past/future injury-related hospitalization or surgery?
Yes
No
Claimant’s Out-of-Pocket Expenses
$______________
Resolution
Actual / Projected
______________________
Resolved?
Yes
No
_ ____________________
______________________
Claimant Bene ts & GRG Requested Services
Claimant
GRG
Claimant
Agency
Bene t Types
Applied
Service
Additional Information Needed if GRG is Engaged
Receiving
Noti ed
For
Requested
(past/present)
Medicare Parts A/B
HIC # _________________________ Entitlement Date _________________________________
(Traditional)
Medicare Parts C/D
Insurance Company Name _____________________ Group/ID # _________________________
(Advantage/Prescription/
Supplemental)
Future Medicals Evaluation
Initial step performed for all Future Medical engagements.
Medicaid (Tort Recovery)
Medicaid # _________________________ State ______________________________________
Insurance Company Name ______________________________
*Please provide plan
Private Health Plan
Group/ID # ___________________________________________
document if available.
(ERISA, Non-ERISA)
If Employer-based Health Plan, specify employer name _________________________________
Provider Direct
Name of Provider(s) (Doctor or Hospital) _____________________________________________
(Doctor or Hospital)
Other Government Plan:
Treating Facilities _______________________________________________________________
VA
Tricare
Sponsor’s SSN (if di erent than claimant’s SSN) ______________________________________
Indian Health Services
SSDI
Income replacement based on disability and work history (relates to Medicare)
(Social Security Disability Insurance)
SSI
Income replacement based on disability and/or age and nancial need (relates to Medicaid)
(Supplemental Security Income)
Carrier/TPA ___________________________ File/Board # ______________________________
Workers’ Compensation
Next Steps: Please email GRG Case Intake Form and all relevant healthcare authorizations to .
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