Common use of Complete Claim Package Requirements Clause in Contracts

Complete Claim Package Requirements. (A) A complete Claim Package must include the following “Supporting Documentation”: (1) A completed and signed Claim Form contained in Appendix E-1; (2) A completed and signed Authorization to Release Records and Other Information contained in Appendix E-2. When executing this document, the Program Participant shall not specify particular healthcare providers for the collection of records, but shall leave the provider field of the form blank so that it may be utilized for collection of any necessary records in accordance with Section 4.06; (3) An executed Release contained in Appendix F-1; (4) In the event of a Plaintiff who asserts a Derivative Claim in the Complaint filed by the Program Participant, an executed Release contained in Appendix F-2, instead of an executed Release contained in Appendix F-1, executed by the Program Participant and by any Plaintiff who asserts a Derivative Claim in the Complaint filed by the Program Participant. For avoidance of doubt, a Release is required from each and every Plaintiff who asserts a Derivative Claim with respect to any Program Participant, but a Release is not required from the spouse of a Plaintiff if the spouse did not assert a Derivative Claim in the Complaint; (5) Contemporaneous prescription records from a pharmacy or medical facility reflecting that the Program Participant was prescribed or provided with NuvaRing, or other substantiating evidence (the “Prescription Records”), it being understood that: (i) “contemporaneous prescription records” refers to records that were created at, or about, the time the prescription was written or NuvaRing provided, and (ii) “other substantiating evidence” may include an affidavit by a healthcare professional attesting to the prescription of NuvaRing; documentation of samples of NuvaRing that were provided to the Program Participant; documentation in hospital records for the Alleged Injury that specifically reference NuvaRing, or such similar evidence that would be admissible in a state or federal court proceeding to establish the Program Participant’s usage of NuvaRing;

Complete Claim Package Requirements. (A) A complete Claim Package must include the following “Supporting Documentation”: (1) A completed and signed Claim Form contained in Appendix E-1H, to include the Claimants assertion that they meet the requirements for one of the six injury levels set forth in Appendix J, attached (the “Eligible Injuries and Adjustments Criteria” or “Criteria”); (2) A completed and signed complete but undated Authorization to Release Records and Other Information contained in Appendix E-2I, executed by Personal Signature. When executing this document, the Program Participant shall not specify particular healthcare providers for the collection of records, but shall leave the provider field of the form blank so that it may be utilized for collection of any necessary records in accordance with the audit provisions set forth in Section 4.068.05; (3) An executed Release contained in Appendix F-1; (4) In the event of a Plaintiff who asserts a Derivative Claim in the Complaint filed by the Program Participant, an executed Release contained in Appendix F-2, instead of an executed Release contained in Appendix F-1, executed The following “Core Medical Records,” certified by the Program Participant and by any Plaintiff who asserts a Derivative Claim in the Complaint filed by the Program Participant’s counsel as either complete or unavailable. For avoidance If any of doubtthe following Core Medical Records are unavailable, a Release is required from each and every Plaintiff who asserts a Derivative Claim with respect to any Program Participant, but a Release is not required certified No Records Statement from the spouse of a Plaintiff if the spouse did not assert a Derivative Claim pertinent provider must be included in the Complaint;Claim Package, unless it is impracticable for Claimant’s Counsel to obtain, and Claimant’s Counsel certifies that he or she exercised due diligence to obtain a No Records Statement from the provider with an explanation why it was impracticable to obtain such Statement. i. Proof of Olmesartan Products usage for thirty (30) or more days, with the first use of an Olmesartan Product beginning on or prior to May 1, 2015, to include: 1. Contemporaneous Prescription Records from all pharmacies that dispensed Olmesartan Products to the Product User for the period spanning first alleged use of Olmesartan Products through the last use of Olmesartan Products; or 2. Contemporaneous Medical Records documenting prescription of Olmesartan Products to the Product User, or Product User’s receipt of samples of Olmesartan Products, if applicable. ii. Complete medical records from all healthcare providers who: 1. diagnosed the Product User’s Alleged Injury; and, if different, 2. provided treatment for the Product User’s Alleged Injury, or, for gastrointestinal symptoms. iii. If not otherwise included in the above-listed records, medical records from all healthcare providers who prescribed Olmesartan Products to the Product User, for the period spanning two years prior to onset of symptoms through two years following either (a) discontinuation of use of Olmesartan, or (b) resolution of the Alleged Injury, whichever occurs last. iv. If not otherwise included in the above-listed records, medical records from all healthcare providers who served as the Product User’s primary care provider, for the period spanning two years prior to onset of symptoms through two years following either (a) discontinuation of use of Olmesartan, or (b) resolution of the Alleged Injury, whichever occurs last. v. Where Prescription Records and/or Medical Records required by this Section 3.03(A)(3) have been lost or destroyed by medical provider(s) and/or pharmacy(ies), the Claimant may submit a Sworn Affidavit attesting that he or she was treated at the relevant medical facility or filled one or more prescriptions at the relevant pharmacy, provided that Claimant’s Counsel also certifies that he, or she, has conducted a diligent search for the records and confirms that the pharmacy or healthcare provider has advised that it lost or destroyed the documents. (4) A Payment Election Form, as required by the Claims Administrator, to indicate the Qualified Settlement Fund (“QSF”) Administrator is to issue any Settlement Payment to such Program Participant through his or her counsel, if represented, subject to and in accordance with the terms of this Agreement and the Qualified Settlement Fund Agreement. If payments are to be made by wire, the Payment Election Form shall include the wire instructions for use by the QSF Administrator. Primary Counsel representing more than one Program Participant may provide one Payment Election Form applicable to all such Program Participants. (5) Contemporaneous prescription records A W-9 Form, which will be made available by the Claims Administrator, providing the information required by such form for Primary Counsel. Each Primary Counsel shall provide only one W-9 Form. (6) A completed lien resolution form in accordance with Article XIII below to indicate any group health plans (government or private) that may have made any payments on behalf of such Program Participant in any way related to such Program Participant’s injury from a pharmacy or medical facility reflecting that the alleged use of Olmesartan Products from the time the Program Participant was prescribed alleges he or provided with NuvaRing, or other substantiating evidence (she first suffered injury from the “Prescription Records”), it being understood that: (i) “contemporaneous prescription records” refers to records that were created at, or about, alleged use of Olmesartan Products through the time the prescription was written or NuvaRing providedExecution Date, and (ii) “other substantiating evidence” may include an affidavit by which includes a healthcare professional attesting private lien resolution opt-out should such Program Participant elect not to the prescription of NuvaRing; documentation of samples of NuvaRing that were provided to the Program Participant; documentation in hospital records for the Alleged Injury that specifically reference NuvaRing, or such similar evidence that would be admissible in a state or federal court proceeding to establish the Program Participant’s usage of NuvaRing;participate.