To Whom It May Concern:
My name is .
I sustained a work injury on .
I agree that First Review, Inc. can submit an allocation to CMS seeking approval of a WCMSA in regard to future medical expenses related to my work injury.
I am requesting a Medicare Set-Aside for future medical treatment related to my work related injury, which has been subject to ongoing litigation in the State of .
It is my understanding that this allocation is supported by the medical and legal documents in my workers' compensation file.
I will self administer the trust.
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