Forms
- Category One Claim Form - Virtual Tour
This is a virtual tour of the Category One Proof of Claim Form starting with a copy of the actual claim form with help buttons and explanations.
- Category Two Election Form
The purpose of this Form was to permit Category One Class Members to become Category Two Class Members and to receive the Matrix Election Payment of $2,000, plus the Cash/Medical Services Benefit, without further Medical Review or audit of their claim, provided that they have appropriately documented Diet Drug use and a diagnosis of FDA Positive regurgitation after Diet Drug use and before the close of the Screening Period.
- Declaration of Dispensing Pharmacy
Use this form only if your medical records are unobtainable. This form must be completed and signed by a representative of the pharmacy that dispensed the Pondimin® and/or Redux™.
- Declaration of Prescribing Physician
Use this form only if your medical records are unobtainable. This form must be completed and signed by the doctor who prescribed Pondimin® and/or Redux™.
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Page was last updated on 1/12/2006 at 3:29:08 PM (EST).