If you are visitIng this page, that means that you are a new client of Messa & Associates! Welcome and thank you, we are honored to serve you.
Below is a list of forms you will need to complete in order to solidify our employment as your legal representation. Each form title is a link - once you click the link, a new tab will open in your browser to a form. You can complete and submit the form right from your browser and easily navigate back to this tab to select the next form.
If you have any questions during this process, please feel free to call the Client Relations Coordinator, Omar Gonzalez, at 215-568-3500. If you need help outside of our business hours (8:30am to 5:30pm), feel free to email Omar at OGonzalez@messalaw.com.
These forms include a Contingent Fee Agreement, HIPAA Authorization, Medicaid Authorization, certification and/or verification. Please complete and submit the set of forms that coincides with the state in which you were injured.
Claimant's spouses should complete and submit a Contingent Fee Agreement to prepare for a possible Loss of Consortium claim. Please complete and submit the form that coincides with the state in which your spouse was injured.
Please complete this form with the names and contact details of all medical providers related to your claim. If there are providers you did not see, just leave those lines blank.
These forms are required for various filings with the court. We may ask you to complete them again in the future. Please complete a verification if your case is in Pennsylvania and both certifications if your case is in NJ.
These authorizations give us permission to request your medical records from your private medical providers, as well as from the Centers for Medicaid/Medicare Services. They also give your medical providers permission to release the records to our firm for litigation purposes.