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Hilliard Law
Opioids PLTFF – SELF Survey
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PERSONAL INFORMATION OF CLAIMANT
Section 1.A: If you hold a PI Claim arising from your own use of opioids(or if such holder is alive and you are completing this form as his/her representative), then the term “Claimant” in this Claim Form refers to the person who used opioids, whether that is you or the person you represent. Please fill out the information below:
Your/Claimant Name:
Your/Claimant's Date of Birth:
MM slash DD slash YYYY
Your/Claimant's Address: (street address, city, state, zip)
Your/Claimant's Full Social Security Number (or Taxpayer ID):
Representative Name (if applicable):
Legal Authority for Representative (if applicable):
PRESCRIBED MEDICATION
Identify any of the following Purdue-brand opioids that the person whose opioid use is the subject of your Non-NAS PI Claim was prescribed. Include evidence of the prescriptions when submitting this Claim Form. (A claim may qualify without prescription if the person who used opioids was a minor at the time the use began.)
Please Select All That Apply
OxyContin
MSContin
Dilaudid
Butrans
Hysingla
DHC Plus
MSIR
OxyFast
Oxy IR
Palladone
Ryzolt
Rhodes Generic (name)
SECTION 4.B: Identify any of the following Medication Assistance Treatment (MAT) drugs prescribed to the person whose opioid use is the subject of your Non-NAS PI Claim. Include evidence of the prescriptions when submitting this Claim Form.(If you selected Easy Payment, SKIP this Section.)
Please Select All That Apply
Buprenorphine
Butrans
Methadone
Suboxone
Zubsoly
Naltrexone
SECTION 4.C: Identify any of the following medications provided to the person whose opioid use is the subject of your Non-NAS PI Claim during or after an opioid overdose. Include evidence of the prescriptions or administration when submitting this Claim Form. (If you selected Easy Payment, SKIP this Section.)
Select All That Apply
Narcan
Evzio
Naloxone
SECTION 5.A: Please mark all that are applicable to your claim.
ADDICTION
Date Addiction began:
MM slash DD slash YYYY
Opioid that started the addiction:
Diagnosis and Date of Opioid Use Disorder:
WITHDRAWALS
Date(s) withdrawal(s) occurred:
OVERDOSE
Date(s) overdose(s) occurred:
JAIL
Date(s) jail sentence(s) began/ended:
The charge(s):
REHAB
Dates of inpatient or outpatient rehabilitation
MEDICAL PROVIDER INFORMATION
SECTION 7.A: In this section, please identify information for the medical providers (prescribing doctors and pharmacies) who prescribed opioids to the person whose opioid use is the subject of your Non-NAS PI Claim:
Name of Prescriber/Pharmacy and Information
Medical Liens
SECTION 8.A: Did any insurance company pay for medical treatment for the opioid-related injuries that gave rise to your Non-NAS PI Claim?
Yes
No
