Request Only Claim Form - Raymond v. Avectus Healthcare Solutions, LLC

MERCY HEALTH / AVECTUS SETTLEMENT REQUEST ONLY 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 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.

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.
ClaimFormNo
Claimant ID*
SECTION I: CONTACT INFORMATION
Name:*
First Last
Name at time of treatment*
Current Mailing Address:*
Street Address Address Line 2 City State Zip Code
Phone Number (primary):*
Current E-Mail Address*
Mercy Account Number (if known):
Please Certify*
- I understand that the parties to the lawsuit have the right to audit my claim and may contact me at the address, phone number, or e-mail address I have provided to do so.
SECTION II: CERTIFICATION OF TREATMENT
Please Certify*
- By submitting this Claim Form, I hereby certify and affirm, under penalty of perjury, that I: (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 was requested to pay, to Mercy Health any amount of money for the treatment received for covered services, other than for copays and deductibles. I understand that only one claim may be submitted per individual.
Date(s) of Treatment:
Location of Treatment:
SECTION III: SIGNATURE
Printed Signature:*
CAPTCHA
Unique ID
Email
This field is for validation purposes and should be left unchanged.

Raymond v. Avectus Healthcare Solutions, LLC

SECTION I: CONTACT INFORMATION

SECTION II: CERTIFICATION OF TREATMENT

SECTION III: SIGNATURE