A hospital Class Member or an authorized agent can complete this Claim Form. The Notice and Claims Administrator may request supporting documentation. The claim may be rejected if any requested
documentation is not provided in a timely manner.
If you are a hospital submitting a Claim Form on your own behalf, you must provide the information requested in “Part 1, Section A,” in addition to the other information requested by this Claim Form.
If you are an authorized agent of one or more Class Member hospitals, you must provide the information requested in Part 1, Section B – AUTHORIZED AGENT ONLY,” in addition to the other information requested by this Claim Form.
You may submit a separate Claim Form for each hospital, OR you may submit one Claim Form for all such hospitals as long as you provide the information required for each hospital on whose behalf you are submitting the form.
If you are submitting Claim Forms both on your own behalf as a Class Member AND as an authorized agent on behalf of one or more Class Members, you should submit one Claim Form for yourself, completing Section A
and another Claim Form or Forms as an authorized agent for the other Class Member(s), completing Section B.
Do not submit a Claim Form on behalf of any Class Member unless that Class Member provided prior
authorization to submit the Claim Form.
In order to qualify to receive a payment from the Settlements, you must complete and submit this Claim Form either on paper or electronically on the Settlement Website, and you may need to provide certain requested
documentation to substantiate your Claim.
Your failure to complete and submit the Claim Form postmarked or filed online by July 3, 2020, will prevent you from receiving any payment from the Settlements. Submission of this Claim Form does not ensure that
you will share in the payments related to the Settlements. If the Notice and Claims Administrator disputes a material fact concerning your Claim, you will have the right to present information in a dispute resolution
process. For more information on this process, visit www.dvtmedslawsuit.com.
CLAIM DOCUMENTATION REQUIREMENTS
Please provide the below information to support your claim for Lovenox® or generic enoxaparin purchased in
Arizona, Arkansas, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts,
Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, South Dakota, Tennessee, Utah, Vermont, West Virginia, and Wisconsin,
other than for resale, from September 21, 2011 through September 30, 2015.
a) Medicare Provider Number (a/k/a CMS Certification Number)
b) National Provider Identifier (NPI)
c) Hospital Name
g) Zip Code
h) Phone Number
i) Date of purchase (invoice date)
j) Item Description
k) NDC Number (a list of NDC Numbers is included with this Claim Form) – e.g., 00000-0000-00
l) Labeled Concentration (Dosage/strength; e.g., 40mg/0.4ML)
m) Type (branded Lovenox or generic enoxaparin)
n) Number of Syringes Purchased
o) Number of boxes/units
p) Cost per Unit
q) Extended Cost
r) Total Net Amount Paid – e.g., $20.00
s) Credits (e.g., for returned products)
t) Rebates received
Information submitted will be kept strictly confidential pursuant to the Protective Order entered by the Court. For your convenience, an exemplar spreadsheet containing these categories is attached at the end of this Claim Form.
In addition, an Excel spreadsheet can be downloaded from the Claim Form page of this website. Please use this format if possible. A list of the NDCs that will be considered by the Notice and Claims Administrator is
provided on the Claim Form page of this website.
If possible, please provide the electronic data in Microsoft Excel, ASCII flat file pipe “|”, tab-delimited, or fixed-width format. Please contact the Notice and Claims Administrator at 1-888-208-9630 or email@example.com with any questions about
the required claims data.
Please provide as much of the requested information as possible. The requested information is by default mandatory for claims of $300,000 or more, although the Notice and Claims Administrator may also require documentation
for claims of less than $300,000. For claims of less than $300,000, you should still provide the information if you can, even if not specifically requested by the Notice and Claims Administrator. Claims that do not have
any documentary substantiation at all may be rejected.
Please note that hospitals can only make claims for Lovenox® and generic enoxaparin purchased by the hospital pharmacy for use at the hospital. Hospitals may not make claims for Lovenox® and generic enoxaparin purchased for
resale. For example, a hospital with an affiliated retail pharmacy could make claims for the Lovenox® and generic enoxaparin it bought to use or dispense at the hospital, but not for Lovenox® and generic enoxaparin it bought
to re-sell at the pharmacy.