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*In order to provide extra protection against Professional Liability exposure, Affiance Partners established the precedent when offering a Self Administration program for Medicare Set Asides.
Simply complete the Master Intake Sheet and forward to our office via fax, email or mail. To assist us with various information needed to complete our file, please be sure to include a copy of the Compromise and Release or Settlement Agreement with the intake form. Once the funding of the MSA has been received, a confirmation email will be forwarded to let you know accordingly. This will enable us to keep you informed about your referral.
The funding check for the Custodial MSA should be made payable to: "Client Name Medicare Set Aside". Payments for Affiance to direct a Self Administered option should be made payable to: "Affiance Partners" and reference the client name. Payments to Affiance for Administration of a Custodial MSA should be made payable to: "Affiance Partners" and reference the client name. |
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