Hidden

PERSONAL INFORMATION OF NAS CLAIMANT AND HIS/HER REPRESENTATIVE

SECTION 1: Fill out the information of the NAS child below:

MM slash DD slash YYYY

MEDICAL PROVIDER INFORMATION

SECTION 3.A.: This section concerns licensed medical providers who have diagnosed the NAS Child with any medical, physical, cognitive or emotional condition resulting from his/her intrauterine exposure to opioids or opioid replacement or treatment medication(s). The diagnoses may include, but are not limited to, the condition known as neonatal abstinence syndrome (“NAS”). Fill out and provide the following information, if known:

SECTION 3.B: Even if you do not know the information sought in Section 3.A, please include with your submission of this Claim Form Competent Evidence that a licensed medical provider has diagnosed the NAS PI Claimant with any medical, physical, cognitive or emotional condition resulting from the NAS Child’s intrauterine exposure to opioids or opioid replacement or treatment medication(s).

Medical Liens

SIGNATURE INFORMATION (You must complete this Part Five regardless of your elections above)

HEIRSHIP DECLARATION / SWORN DECLARATION ( SIGNATORY IS EXECUTOR UNDER DECEDENT’S LAST WILL AND TESTAMENT)

I. DECEDENT (DECEASED) INFORMATION

MM slash DD slash YYYY

II. PI CLAIMANT INFORMATION

Drop files here or
Max. file size: 250 MB.

    III. HEIRS AND BENEFICIARIES OF DECEDENT

    Use the space below to identify the name and address of all persons who may have a legal right to share in any settlement payment on behalf of the claim of the Decedent. Also, state if and how you notified these persons of the settlement, or the reason they cannot be notified.

    Drop files here or
    Max. file size: 250 MB.