Main Class Claim Form

Transcription

1 Main Class Claim Form (for MAOs and MAO Related Entities) COMPLETED FORM MUST BE POSTMARKED NO LATER THAN OCTOBER 1, 2018, AND MAILED TO: MSPA Claims 1, LLC, v. Ocean Harbor Casualty Insurance Company c/o A.B. Data, Ltd. P.O. Box Milwaukee, WI Make Sure You Sign and Date This Claim Form. For More Information Please Visit the Settlement Website: Please Type or Print Legibly Legal Entity Name: Organization Marketing Name: Federal Tax Identification Number: NPPES NPI Registry Number: Name and Title/Relationship of Person Completing Form on behalf of Main Class Member Name: Title/Relationship to Class Member: Current Mailing Address: (for receiving settlement related communications and payment) Electronic Mail ( ) Address: (as additional means of communications) Proof of Status as an MAO Entity or MAO Related Entity MAO Entities please provide your Medicare Advantage Contract No. below: 1

2 MAO Related Entities please attach copies of documents establishing that the Medical Care and Treatment, for which reimbursement is sought, was provided pursuant to a Medicare Advantage Contract. Please briefly specify below the type of documentation that is being attached. PLEASE INDICATE THE METHOD YOU WILL BE USING TO IDENTIFY YOUR CLAIMS: Self-Identification Administrator-Assisted Identification Self-Identification: CLAIM SUBMISSIONS If you have chosen to self-identify your claims, your claims must be submitted NO LATER THAN OCTOBER 1, Your claim submissions MUST contain the following information: o Date of Loss/Motor Vehicle Accident; o Beneficiary Name; o Beneficiary Date of Birth; o HICN (or SSN if HICN is not available); o Description of Medical Care and Treatment (including CPT Codes and any DX Codes, and the Dates of Service); o Date Medical Care and Treatment is Provided to Beneficiary; and, o Proof of payment or proof of financial liability for the Medical Care and Treatment. Your claim submissions MUST also be formatted as specified by the Settlement Administrator. The Settlement Administrator will provide you with instructions regarding the required format no later than 7 days after the Settlement Administrator s receipt of your Claim Form. Administrator-Assisted Identification: If you have chosen to have the Settlement Administrator assist in identifying your claims, your potential claims data must be submitted NO LATER THAN OCTOBER 1, Your potential claims data MUST contain the following information: o Beneficiary Name; o Beneficiary Date of Birth; o HICN (or SSN if HICN is not available); 2

3 o Description of Medical Care and Treatment (including CPT Codes and any DX Codes, and the Dates of Service); o Date Medical Care and Treatment is Provided to Beneficiary; o Proof of payment or proof of financial liability for the Medical Care and Treatment. Your potential claims data MAY contain the following information if available: o Date of Loss/Motor Vehicle Accident. Your potential claims data submissions MUST also be formatted as specified by the Settlement Administrator. The Settlement Administrator will provide you with instructions regarding the required format no later than 7 days after the Settlement Administrator s receipt of your Claim Form. 3

4 NOTICE TO MAO ENTITIES If a MAO Related Entity paid or is financially liable for the Qualifying Motor Vehicle Accident Expenses for the Beneficiary s Medical Care and Treatment, the MAO Entity should forward the Class Notice to that MAO Related Entity and it should return this Claim Form with the below acknowledgment identifying that MAO Related Entity that paid or is financially liable for the expenses. An MAO Related Entity, (Legal Name of MAO Related Entity) paid or is financially liable for the expenses for which reimbursement may be sought under the Settlement Agreement. That MAO Related Entity s contact information is as follows:. Signature of Person Completing Claim Form TAX CONSEQUENCES OF SETTLEMENT Settlement Class Members should consult their own tax advisors regarding any tax consequences of this Settlement, including any payments or benefits under the Settlement Agreement and any tax reporting obligations with respect to the Settlement Agreement. AFFIRMATION I swear under the penalty of perjury under the laws of the State of Florida that: I have reviewed the Class Notice and I reasonably believe that the MAO Entity or MAO Entity for whom I am completing this Claim Form is entitled to relief pursuant to the terms of the Settlement Agreement; The MAO Entity or MAO Related Entity holds the legal right to receive PIP Benefits under the subject insurance claim; which right has not been otherwise assigned or transferred to another person or entity; No rights or claims asserted by the MAO Entity or MAO Related Entity on this Claim Form have been otherwise resolved, discharged, settled, or released; No payments have been made by or on behalf of the Beneficiary for any amounts other than for Out of Pocket Expenses; 4

5 I have provided reasonably available documents relating to this Claim Form submission; I agree to reasonably cooperate in verifying and quantifying any amounts for which reimbursement is sought under this Claim Form and I agree to reasonably provide additional supporting documentation upon reasonable request from the Settlement Administrator or Ocean Harbor; The MAO Entity or MAO Related Entity agrees that, as set forth in the Class Notice, the MAO Entity or MAO Related Entity is releasing all claims against Ocean Harbor and the Released Parties in accordance with this Settlement Agreement and the Court's orders approving this Settlement; and, The MAO Entity or MAO Related Entity additionally agrees that before it receives any Settlement Payment, it will execute a written release in favor of Ocean Harbor and the Released Parties of all Released Claims (as those terms are defined in the Settlement Agreement), which written release will remain valid upon my acceptance of the Settlement Payments even if the Final Judgment on the Settlement is later reversed and/or vacated on appeal. Name: Date: Signature of Person Completing Claim Form: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree. 5