Final Settlement Detail Document
Beneficiary Name:
Medicare Number:
Date of Incident:
Case Identification Number:
Please supply the information outlined below to help Medicare to properly calculate the amount
it is due. This information will also be used to update your records.
Total Amount of the Settlement: _______________________
Total Amount of Med-Pay or PIP: _______________________
**only if paid directly to the beneficiary
or the beneficiary’s representative
Attorney Fee Amount Paid by the Beneficiary: _______________________
Additional Procurement Expenses Paid by the Beneficiary: _______________________
(Please submit an itemized listing of these expenses)
Date the Case Was Settled: _______/________/_______
Description of Injuries: _______________________
Name of person who is providing this information: _______________________
Relationship with the Beneficiary: _______________________
This information should be submitted to:
PO Box 138832
Oklahoma City, OK 73113
If you have any questions concerning this matter, please contact the Benefit Coordination &
Recovery Center (BCRC) by phone at 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the
hearing and speech impaired), in writing at the address above, or by fax to 405-869-3309. When
sending correspondence, please include the Beneficiary Name along with the Medicare and Case
Identification Numbers (shown above).