MERCY HEALTH / AVECTUS SETTLEMENT CLAIM FORM
If you (a) received treatment at a Mercy Health facility in Ohio between August 27, 2009, and August 31, 2023; (b) in conjunction with that treatment, presented evidence to Mercy Health of health insurance through a plan accepted by Mercy Health; and (c) thereafter paid, or were requested to pay, to Mercy Health any amount of money for treatment received for services covered by your health insurance plan, other than for copays and deductibles, if any, and you have not previously released all claims as to Mercy Health and Avectus, then as a result of a Settlement with Mercy Health and Avectus you are eligible to receive a cash payment of up to $25 plus up to 50% of any payment you made or an attorney made on your behalf to Mercy Health for covered services, other than for copays and deductibles.
The amount of the payment will be determined based on a formula contained in the Settlement Agreement. Additional information regarding the formula and the Settlement can be found in the Settlement Agreement.
Only patients who presented evidence of insurance to Mercy Health through a plan accepted by Mercy Health and then paid, or were requested to pay, money to Mercy Health for services covered by your health insurance plan, other than for copays and deductibles, are eligible to receive payment, and only one claim may be submitted per individual.
Please Complete Each Section In The Space Provided. Incomplete Claim Forms Will Be Ineligible For A Payment.