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Purdue Pharma PI Claim Questionnaire instructions

Purdue Pharma PI Claim Questionnaire instructions

Purdue Pharma PI Claim Questionnaire instructions

This is not the official Claim Form. An official Claim Form will be required in the future in order to enroll in any settlement program. At this time, we are gathering as much information as possible so that we may complete the final Claim Forms in a timely manner.

Please complete this form as completely and thoroughly as you can. When the final Claim Form is approved we will send you a draft to review and sign.

Follow the instructions of each section carefully to ensure that your Questionnaire is submitted correctly. If any section does not pertain to your claim, leave it blank. Submitting this Questionnaire does not guarantee that you will receive payment from the PI Trust. Whether or not you receive payment depends on whether you make the additional required submissions, including medical or pharmacy records showing usage of a qualifying drug, and whether or not your claim meets the eligibility requirements.

If you have not already sent us records showing use of a qualifying drug, or contacted our office, please do so as soon as possible.

Instructions for Submission: You may complete and submit this Questionnaire either here or by mailing to:

PEIFFER WOLF CARR KANE & CONWAY, LLP
1519 ROBERT C. BLAKES SR DR., 1ST FLOOR
NEW ORLEANS, LA 70130

PART ONE: PERSONAL INFORMATION OF PI CLAIMANT

Claimant’s Address

If you are filing a PI Claim due to another’s death from use of opioids, please fill out the information below information below.
PART TWO: PRESCRIBED MEDICATIONS
Section 2.A: Identify any of the following Purdue brand opioids that the opioid user who is the subject of your PI Claim was prescribed. Please provide evidence of this prescription if you have not done so already.
Section 2.B: Identify any of the following Medication Assistance Treatment (MAT) drugs prescribed to the opioid user who is the subject of your PI Claim. Please provide evidence of this prescription if you have not done so already.
Section 2.C: Identify any of the following medications provided to the opioid user (whether you or another person) during or after an opioid overdose. Please provide evidence of this prescription if you have not done so already.
PART THREE: OPIOID USER AND OPIOID CLAIMANT INJURIES
Section 3.A: Please mark all that are applicable to your claim.
PART FOUR: MEDICAL PROVIDER INFORMATION
Section 4.A: In this section, please identify information for the medical providers (prescribing doctors and pharmacies) who prescribed opioids to the opioid user that is the subject of your PI Claim:
PART FIVE: MEDICAL PROVIDER INFORMATION
Section 5.A: Did any insurance company pay for medical treatment for the opioid-related injuries that gave rise to your PI Claim?
Section 5.B: In the last 20 years, was the opioid user who is the subject of your claim eligible for coverage by any of the following, or did any of the following actually pay for his/her opioid-related health costs? Respond by writing “Yes” or “No” next to each insurance provider name, and provide the requested information as to each. If any insurance carrier who provided coverage to the opioid user is not identified, please fill in that carrier’s information at the bottom of the chart.