CLAIM FORM AND INSTRUCTIONS FOR THE ANTHEM SETTLEMENT FUND CLAIM FORM INSTRUCTIONS

Transcription

1 CLAIM FORM AND INSTRUCTIONS FOR THE ANTHEM SETTLEMENT FUND CLAIM FORM INSTRUCTIONS IT IS VERY IMPORTANT THAT YOU READ THE ENCLOSED NOTICE OF PROPOSED SETTLEMENT IN ORDER TO FULLY UNDERSTAND YOUR RIGHTS UNDER THIS SETTLEMENT. DEADLINE FOR SUBMISSION: Postmarked by August 9, 2012 WE STRONGLY RECOMMEND SENDING YOUR CLAIM FORM VIA REGISTERED, CERTIFIED, OR OVERNIGHT MAIL AND RETAINING YOUR RECEIPT AND A COPY OF YOUR CLAIM FORM FOR YOUR RECORDS. If you validly submit a Claim Form to the Settlement Administrator postmarked by no later than August 9, 2012, you may be entitled to receive a portion of the Settlement Fund. A Settlement Class Member may file only one Claim Form. By submitting a Claim Form, you are agreeing to be subject to the jurisdiction of the United States District Court for the Southern District of Florida for any proceedings relating to your Claim Form or any suit, action, proceeding, case, controversy, or dispute that arises from or relates to in any manner the settlement of this action. Capitalized terms used in this Claim Form that are not otherwise defined herein have the meaning assigned to them in the Settlement Agreement. A copy of the Settlement Agreement can be found on: Mail your completed Claim Form, with any required documentation, to the Settlement Administrator at the following address: Via United States Postal Service: Tilghman & Co. P.C. P.O. Box Birmingham, AL Via UPS or Federal Express: Tilghman & Co. P.C Independence Drive, Suite 102 Birmingham, AL NOTE: YOU MUST NOTIFY THE SETTLEMENT ADMINISTRATOR IMMEDIATELY OF ANY CHANGE IN YOUR ADDRESS, TO AVOID HAVING YOUR MAILED CHECK RETURNED TO THE SETTLEMENT ADMINISTRATOR AND REMITTED TO THE CONNECTICUT STATE DENTAL ASSOCIATION FOUNDATION. YOU MUST ALSO CASH ANY CHECK YOU RECEIVE WITHIN 60 DAYS OF ISSUANCE. ANY UNCLAIMED FUNDS WILL BE REMITTED TO THE CONNECTICUT STATE DENTAL ASSOCIATION FOUNDATION. Individual dentists who are members of the Class (as described in the enclosed notice of proposed settlement) are entitled to receive a pro rata amount of the portion of the Settlement Fund. Your settlement payment will be based on a reasonable estimate of the percentage of the Class Period that you were a Participating Provider with Anthem. The Settlement Administrator will calculate the amount due to each individual Settlement Class Member who has validly submitted a Claim Form prior to the Deadline for Submission by assigning one point to that dentist for each calendar year during the period from April 15, 1996 through April 14, 2002 in which he or she was an Anthem Participating Provider for any portion of that year. An individual dentist may be assigned a maximum of seven points. After the Deadline for Submission of Claim Forms has passed, the Settlement Administrator shall divide the Residual Corpus by the total number of points assigned to eligible Settlement Class Members on the basis of timely, valid Claim Forms received in order to establish the monetary value of each point (the Point Value ). An individual Settlement Class Member s Share of the Settlement shall be calculated by multiplying the number of points assigned to that Settlement Class Member by the Point Value. Individual dentists who wish to submit a claim on their own behalf (or their legal representatives or heirs) should complete the Section A of this Form. Please note that with the individual dentists authorization, Provider Groups and Provider Organizations may submit Claim Form(s) on behalf of eligible dentists who are, or were, members of that Provider Group or Organization 1 of 8

2 during the Class Period and who are not also submitting Claim Forms on their own behalf. Provider Groups and Organizations are not entitled to any points, and any payments from the Settlement Fund will be made to individual Settlement Class Members. The seven-point maximum will apply to every individual Settlement Class Member regardless of whether he or she participated in a Provider Group or Organization and regardless of whether the Claim Form is submitted by the Settlement Class Member or by a Provider Group or Organization on the Member s behalf. Provider Groups and Provider Organizations who wish to submit claims on an individual dentist s behalf should complete Sections B of this Form. The Settlement Administrator will make the final decision on any dispute regarding the eligibility of a Settlement Class Member to receive payment from the Settlement Fund or the amount of any such payment. Any questions about this procedure should be addressed to the Settlement Administrator at: Via United States Postal Service: Tilghman & Co., P.C. P.O. Box Birmingham, AL Via UPS or Federal Express: Tilghman & Co., P.C Independence Drive, Suite 102 Birmingham, AL Or you may also contact the Settlement Administrator at: or Any Claim Form postmarked after August 9, 2012 is not a Valid Claim Form and will be denied by the Settlement Administrator. IF YOU HAVE QUESTIONS ABOUT THE SETTLEMENT FUND OR ABOUT THE PROCEDURE FOR FILING A CLAIM FORM, CONTACT THE SETTLEMENT ADMINISTRATOR AT OR CLASS COUNSEL AT (203) DO NOT CONTACT THE COURT OR ANTHEM WITH QUESTIONS ABOUT THE SETTLEMENT. 2 of 8

3 CLAIM FORM -- SECTION A FOR DENTISTS SUBMITTING CLAIM FORMS ON THEIR OWN BEHALF You must read the Notice of Proposed Settlement and Claim Form instructions before completing this Claim Form. The capitalized terms used in this Claim Form are defined in the Settlement Agreement. A Settlement Class Member may file only one Claim Form. Do not submit a Claim Form on your own behalf if you have authorized a Provider Group or Organization to do so on your behalf. I do declare and certify as follows: I have reviewed the enclosed notice of proposed settlement and I am a member of the Settlement Class (as described in the Notice of Proposed Settlement and defined in the Settlement Agreement) or a legal heir or representative of a deceased Settlement Class Member; I have not opted out of the Settlement Class and Settlement; To my knowledge, no Provider Group or Organization is submitting a Claim Form on my behalf; and All of the statements and information provided in this Claim Form are true, correct and complete. Print Name of Dentist Name of Representative* (if dentist is deceased) Signature Date Address Telephone Number Address (optional) * If you are the legal heir or representative of a deceased Settlement Class Member, you must attach documentation such as a death certificate or letters of administration for an estate to confirm your status. The Tax ID requested below in the Substitute W-9 is that of the heir or estate. 3 of 8

4 Please select ONLY ONE of the following TWO options: By checking this box, I certify that I was a Participating Provider with Anthem for the entire period of April 15, 1996 through April 14, By checking this box, I certify that I was a Participating Provider with Anthem for a part of the period April 15, 1996 through April 14, 2002, including at least some portion of the following years (please check all that apply): Please provide the name of the individual dentist, Provider Group/ Provider Organization that you believe held the Provider Contract(s) under which you participated for all, or part of, the period of April 15, 1996 through April 14, If you can, please specify the period of time under which you participated in the Provider Contract. Name of entity or person TIN/SSN Dates of participation that contracted with Anthem or Blue Cross Blue Shield of CT Name of entity or person TIN/SSN Dates of participation that contracted with Anthem or Blue Cross Blue Shield of CT Name of entity or person TIN/SSN Dates of participation that contracted with Anthem or Blue Cross Blue Shield of CT [If you wish to list more than three (3) entities, please attach a separate sheet.] 4 of 8

5 CLAIM FORM -- SECTION A SUBSTITUTE FORM W-9 Please enter the Social Security Number (or, for deceased dentists, the Tax Identification Number of the heir or estate) below of the claimant whose name will appear on any check and related Form Social Security Number OR Tax Identification Number I certify that: (1) The number shown on this form is my correct Social Security Number (or Tax Identification Number); (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. Citizen. The IRS does not require your consent to any provision of this document other than certifications (1)-(3) above required to avoid back-up withholding. NOTE: Backup withholding is extra tax withholding that occurs when a taxpayer has underreported interest or dividends in a previous year. The IRS notifies taxpayers who are subject to back-up withholding. If you (the claimant) have been notified by the IRS that you are subject to back-up withholding because you have failed to report all interest and dividends on your tax return, you must cross out item number 2 above by placing a line through the section. The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding. Signature Date 5 of 8

6 CLAIM FORM -- SECTION B FOR PROVIDER GROUPS AND ORGANIZATIONS SUBMITTING CLAIM FORMS ON BEHALF OF INDIVIDUAL SETTLEMENT CLASS MEMBERS You must read the Notice of Proposed Settlement and Claim Form instructions before completing this Claim Form. The capitalized terms used in this Claim Form are defined in the Settlement Agreement. A Settlement Class Member may file only one Claim Form. Do not fill out on behalf of any individual dentists that are submitting Claim Forms on their own behalf. I do declare and certify as follows: I am an authorized representative of the Provider Group or Organization identified on this form; I have reviewed the enclosed notice of proposed settlement and members/former members/employees of [Provider Group or Organization Name] identified on this form are a member(s) of the Settlement Class (as described in the Notice of Proposed Settlement); The individual Settlement Class Members Identified on this form have authorized this Provider Group or Organization to submit Claim Form(s) on their behalf; To my knowledge, I am not submitting a Claim Form on behalf of any individual Settlement Class Members who are submitting Claims Forms on their own behalf; and all of the statements and information provided in this Claim Form are true, correct and complete Dentist Name Social Security No. Dental Practice Tax ID No. [If you wish to list more than five (5) Settlement Class Members, please attach a separate sheet.] Please select ONLY ONE of the following TWO options: By checking this box, I certify that all of the above Settlement Class Members were Participating Providers with Anthem for the entire period of April 15, 1996 through April 14, By checking this box, I certify that the above Settlement Class Members were Participating Providers with Anthem for a part of the period of April 15, 1996 through April 14, 2002, including at least some portion of the following years (please check all that apply): Dentist Name Years as Anthem Participating Provider of 8

7 [If you wish to list more than five (5) individual dentist Settlement Class Members, please attach a separate sheet.] Group/Organization Name Group/Organization Tax Identification Number(s) Address of Group/Organization Telephone Number Printed Name of Individual Submitting Form Title or Position with Provider Group/Organization Signature Date Address (optional) 7 of 8

8 CLAIM FORM -- SECTION B SUBSTITUTE FORM W-9 I certify that: (1) The Social Security Number(s) shown on this form are the correct Social Security Numbers for the dentists listed on this form Section B and whose names will appear on any check and related Form-1099; (2) These claimants are not subject to backup withholding because: (a) they are exempt from backup withholding, or (b) they have not been notified by the Internal Revenue Service (IRS) that they are subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified them that they are no longer subject to backup withholding; and (3) The claimants are U.S. Citizens. The IRS does not require your consent to any provision of this document other than certifications (1)-(3) above required to avoid back-up withholding. NOTE: Backup withholding is extra tax withholding that occurs when a taxpayer has underreported interest or dividends in a previous year. The IRS notifies taxpayers who are subject to back-up withholding. If they (the claimants) have been notified by the IRS that they are subject to back-up withholding because they have failed to report all interest and dividends on their tax return, you must cross out item number 2 above by placing a line through the section. The Internal Revenue Service does not require consent to any provisions of this document other than the certifications required to avoid backup withholding. Signature Date 8 of 8