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Green Form (To Apply For Matrix Compensation Benefits) - Pennsylvania
| Green Form (To Apply For Matrix Compensation Benefits) Form. This is a Pennsylvania form and can be used in AHP Settlement Trust Statewide . |
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GREEN FORM Diet Drug Settlement With American Home Products Corporation Part I: Part II: Part III: Matrix Compensation Benefits Claim Form (to be completed by Claimant or Claimant's Representative) Doctor's Evaluation Form (to be completed by Physician) Claimant's Lawyer Statement (to be completed if you are represented by an Attorney) Appendix: Settlement Matrix Compensation Benefits Guide for Physicians, Attorneys and Class Members Do not detach or separate bound Claim Forms. To receive Matrix Compensation Benefits, you must complete the BLUE FORM in addition to this GREEN FORM. Part I -- To the Claimant(s): 1. This form should be used if you believe that you are entitled to Matrix Compensation Benefits under the Diet Drug Settlement Agreement with American Home Products Corporation. These Benefits are described generally in the official notices authorized by the Court and in the "Settlement Matrix Compensation Benefits Guide for Physicians, Attorneys and Class Members," which is an Appendix to this form. If you are the individual who used the diet drugs Pondimin® (Fenfluramine) and/or ReduxTM (Dexfenfluramine) and who has a condition which you believe qualifies for a Matrix Compensation Benefit, state your name, birth date, Social Security Number and, if known, the Claim Number that you have received from the AHP Settlement Trust. If you are making this Claim as the guardian, executor, administrator, or other legal representative of a living person or the estate of a deceased person, or as a Derivative Claimant, such as a spouse, child, dependent, parent, other relative or "significant other" of the person who used the diet drugs Pondimin® ("Fenfluramine") and/or ReduxTM ("Dexfenfluramine") and who has (or had) a condition which you believe qualifies for a Matrix Compensation Benefit, state the name, birth date, and Social Security Number of the person who used the diet drugs and, if known, the Claim Number received from the AHP Settlement Trust relating to the Diet Drug Recipient. (First Name of Diet Drug Recipient) (Middle Initial) (Last Name) / / 18300 (Birth Date MM/DD/YYYY) (Social Security Number) (Claim Number, if known) Remove the GREEN FORM label from the Notice Package, affix here and fill out all information above. Mail this form to: AHP Settlement Trust 1100 E. Hector Street Suite 450 Conshohocken, PA 19428 For assistance, call 1-800-386-2070 Or access http://www.settlementdietdrugs.com GREEN FORM - 1 American LegalNet, Inc. www.FormsWorkFlow.com 2. If you seek Matrix Compensation Benefits, you must complete this GREEN FORM if and when the Diet Drug Recipient has a Matrix-Level medical condition. If you have qualified for and have been paid a Matrix Compensation Benefit, then you preserved your right to receive incremental payments if the Diet Drug Recipient's medical condition has worsened and the change places your Claim on a higher level of the payment Matrix. To seek additional payment based on a worsened medical condition, you must complete another GREEN FORM. Check the appropriate box below: 3. This is an original GREEN FORM This is a GREEN FORM seeking additional payment for a worsened medical condition. If you are submitting this form as the Representative of the estate of the Diet Drug Recipient, or on behalf of a Diet Drug Recipient who has become incapacitated, complete the information below: (First Name of Representative) (Middle Initial) (Last Name) (Street Address) (City) (State) (Zip Code) ( ) ( ) (Daytime Area Code & Phone Number) (Evening Area Code & Phone Number) (E-mail Address, if any) (Legal Relationship to Diet Drug Recipient [trustee, power of attorney, etc.]) NOTE--If you have not previously provided to the AHP Settlement Trust a copy of the court order or other document appointing you as the personal representative of the Diet Drug Recipient, you must attach or include a copy of your court approval or other authorization to represent the Diet Drug Recipient in this Settlement with your completed GREEN FORM. Check whichever box is applicable: I have already provided the requested documentation previously or on another form and there is no change. A copy of my court approval or other authorization to represent the Diet Drug Recipient is attached. GREEN FORM - 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. If you are submitting this form as a Derivative Claimant, (i.e., a spouse, parent, child, dependent, relative, or "significant other" of a Diet Drug Recipient), complete the information below: a. (NOTE--Current and correct information is required for all Derivative Claimants. If there is information for more than one Derivative Claimant, check here and then use a blank piece of paper or a photocopy of this question to provide the information for each applicable Derivative Claimant. Include that paper with this form. Be advised that a single benefit amount in accordance with Matrix A-2 or B-2 (See pages 17-18 of the Appendix) will be apportioned between all eligible Derivative Claimants.) (First Name) (Middle Initial) (Last Name) (Street Address) (City) (State) (Zip Code) ( ) ( ) (Daytime Area Code & Phone Number) (Evening Area Code & Phone Number) (E-mail Address, if any) / / (Date of Birth MM/DD/YYYY) (Social Security Number) b. Specify the relationship of the Derivative Claimant to the Diet Drug Recipient. Spouse Parent Child Dependent, specify Other relative, specify Significant other, specify c. If you selected "Spouse" above, what is the current status of the relationship of the Derivative Claimant to the Diet Drug Recipient? Married Divorced Separated / Widowed Date of the Marriage: / (MM/DD/YYYY) GREEN FORM - 3 American LegalNet, Inc. www.FormsWorkFlow.com d. If the Derivative Claimant is a Spouse who is currently estranged from the Diet Drug Recipient, state the date of separation and/or divorce. Date: / / (MM/DD/YYYY) (Provide evidence of the date of separation or divorce, i.e., separation agreement or divorce decree.) e. Identify the basis on which the Derivative Claimant is claiming "derivative" benefits. Loss of Consortium/Per Quod (e.g., loss of marital services and relationship) Loss of Support Loss of Service Other, explain: NOTE: If you are completing this questionnaire as a Representative or Derivative Claimant, the following questions using the term "You" refer to the "Diet Drug Recipient." 5. Check which Matrix Level of Severity (see Appendix pages 18-21) you believe you currently qualify for
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