Is a Medicare Set-Aside Arrangement (MSA) required? Is it anticipated that there will be future medical expenses relating to my client’s injury? Yes No Is my client a Medicare beneficiary? Yes No Is my client receiving SSDI or RRD? Yes No Has my client applied for SSDI or RRD or had my client applied and been denied but anticipates appealing the decision? Yes No Is my client in the process of appealing and/or refilling for SSDI or RRD benefits? Yes No Is my client age 62.5 years or older? Yes No Does my client have End Stage Renal Disease (ESRD) but does not yet qualify for Medicare based on ESRD? Yes No Does my client have Amyotrophic Lateral Sclerosis (ALS)? Yes No Name: Email: Phone: Δ If the answers to questions 1 is YES and then the answer to any questions between 2 and 7 is YES then an MSA is required.