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Voluntary YAZ Private Lien Resolution Program
Claimant Information
I. General Information
You may have received health insurance benefits from a Private Health Plan Provider.
Please read this document and immediately take the steps noted if you would like to
participate in the Voluntary YAZ Private Lien Resolution Program described below.
The Settlement in which you are participating may require your cooperation concerning
reimbursement claims and obligations related to private healthcare benefits you received. This
packet applies to you if you have received benefits relating to your injury from healthcare
coverage or insurance through a private insurance carrier (collectively referred to in this packet
as “Private Health Plan Provider”), including but not limited to the following:
Health coverage provided through you or your spouse’s employer (applies
to both private company employers and government employers), or
Health coverage that you purchased privately.
As a general matter, private healthcare coverage is provided to you in accordance with a written
policy or plan. In the event that you received benefits through one of the private coverage
groups above, that group MAY have a plan or policy which requires you to (1) notify of them of
your claim or Settlement and/or (2) reimburse them from your Settlement for injury related care
provided; this is known as a “healthcare lien.” Thus you MAY have an obligation to notify and
reimburse your Private Health Plan Provider. If such an obligation exists and the Private Health
Plan Provider is not notified and reimbursed from your Settlement, the Private Health Plan
Provider may seek the following actions if provided in your plan or policy: (i) instituting legal
proceedings against you for benefits provided, (ii) offsetting the amount of benefits provided
against future claims, or (iii) terminating your coverage.
If you have received any correspondence from your Private Health Plan about your claims
against BAYER and/or anticipated Settlement Payment, please notify your attorney
immediately.
II. What Are My Options?
If you have received injury related care from a Private Health Plan Provider you have the
following options:
1) Voluntarily Participate in the YAZ Private Lien Resolution Program (described
below)
a. Participation in the YAZ Private Lien Resolution Program will ensure that if your
Private Health Plan Provider is participating (see Exhibit 1), any obligation on
your part is satisfied. Furthermore, it limits the amount which you may be
obligated to repay and may allow you to receive your settlement sooner. If your
Private Health Plan Provider is not listed on Exhibit 1 you can still participate and
by listing your Private Health Plan Provider on the YAZ Private Lien Resolution
Program Offer and Acceptance form the Administrator will make its best efforts
to contact your Private Health Plan Provider and encourage the Private Health
Plan Provider to participate according to the terms and conditions.
2) Not Participate in the YAZ Private Lien Resolution Program
a. If you choose not to participate in the YAZ Private Lien Resolution Program you
will be responsible for addressing any potential private health plan lien which
may exist. If you fail to address and resolve any such lien you may be held
responsible by your Private Health Plan Provider and it may impact your future
coverage under this plan. Furthermore, according to the terms of the settlement
agreement and release between settling Claimants and Bayer, Bayer will continue
to hold a portion of your settlement funds until any such lien is resolved or 2 years
elapse without Bayer being made aware of a lien interest.
III. What Is The YAZ Private Lien Resolution Program?
The terms of your contract with your Private Health Plan Provider(s) may state that the Provider
is entitled to reimbursement for the cost of your treatment alleged to be caused by a third party.
This contractual reimbursement right would then extend to your YAZ-related medical care
should you receive a Settlement Payment. For example, if your Private Health Plan Provider paid
$10,000 for your medical care related to your use of YAZ and resulting complications, the terms
of your insurance policy contract with your Private Health Plan Provider may require you to
repay that $10,000 from your Settlement Payment. This is known as a “healthcare lien.”
The YAZ Private Lien Resolution Program has been established to resolve certain Private Health
Plan Provider interest in a manner that the Garretson Resolution Group, the Administrator of the
Private Lien Resolution Program, believes is favorable to the affected Claimants. The primary
benefit to participating claimants is that certain Private Health Plan Providers have entered into
an agreement with certain Plaintiffs’ Counsel which obligates the Providers to reduce the amount
of a client’s lien repayment obligation by at least 50%.
The program is entirely voluntary. You are not obligated to participate. However, if you
choose not to participate, you may still be responsible for resolving any lien claimed by
your Private Health Plan Provider, and that Provider may not offer you the 50% reduction
and overall cap (described below) in lien amount that is provided by this program. This
document explains the program’s mechanics should you choose to participate.
Claimants may voluntarily elect to participate in the program according to its terms and
conditions, regardless of whether their Private Health Plan Provider has yet notified them of a
YAZ-related lien. A complete list of the Private Health Plan Providers participating in this
Voluntary YAZ Private Lien Resolution Program is contained in Exhibit 1, attached.
IV. What Are The Terms and Conditions of The YAZ Private Lien Resolution Program?
Eligibility – Exhibit 1 contains a listing of the Private Health Plan Providers who are currently
participating in the Voluntary YAZ Private Lien Resolution Program. If you have received
healthcare benefits from any of the Private Health Plan Providers listed on Exhibit 1, you are
eligible to participate in this Voluntary YAZ Private Lien Resolution Program. Since many
Claimants may not know the proper name of their health care program, if you have any doubt as
to whether your insurance provider is participating in this Program, you may still follow the steps
below and the Lien Resolution Administrator will take appropriate steps to verify whether or not
your Private Healthcare Plan is participating in the Program. If your Private Health Plan
Provider is not listed on Exhibit 1 you can still participate and by listing your Private Health Plan
Provider on the YAZ Private Lien Resolution Program Offer and Acceptance form the
Administrator will make its best efforts to contact your Private Health Plan Provider and
encourage the Private Health Plan Provider to participate according to the terms and conditions.
If a Private Health Plan Provider does not voluntarily agree to participate in the Program then the
Provider is not bound by terms of the Program.
Audit – If you choose to participate and if your Private Health Plan Provider is participating in
the Program, the Garretson Resolution Group will obtain from your Private Health Plan Provider
its documentation regarding the YAZ-related expenditures it made on your behalf (“claimed
expenditures”). Sometimes claimed expenditures might inadvertently include claims for charges
that are not related to your YAZ use or subsequent injuries. These are known as “unrelated
charges” and they will not be included in the total amount of the lien. For example, if a YAZ-
related lien for $10,000 contains $2,000 worth of unrelated charges, the auditing process will
identify those and reduce the lien amount to $8,000 (“Injury-Related Lien Amount”). This
ensures that your repayment obligation does not include any expenditures unrelated to YAZ.
Lien Reductions and Caps - As part of the Voluntary YAZ Private Lien Resolution Program,
the participating Private Health Plan Providers have agreed to reduce automatically all post-audit
Injury-Related Lien Amounts by 50% (“Adjusted Lien Amount”). In addition to automatically
reducing all participating Private Health Plan Provider liens by 50%, the participating Private
Health Plan Providers have also agreed to limit or “cap” a lien at 15% of Gross Settlement
Amount (“Capped Lien Amount”) when only one Private Health Plan Provider has a lien. In the
event that two or more Private Health Plan Providers have a lien against the same claimant the
cap is 17.5% of Gross Settlement Amount and the Private Health Plan Providers will split a pro
rata share of the Capped Lien Amount. A claimant’s repayment obligation under the Program
will be limited to the lesser of the Capped Lien Amount or Adjusted Lien Amount.
Example A: If your Gross Settlement Amount is $20,000 and your Private Health Plan Provider
paid $10,000 for your medical care related to YAZ, the $10,000 lien amount will be reduced by
50% to $5,000 (Adjusted Lien Amount). The Adjusted Lien Amount will then be capped at only
15% of the total Gross Settlement Amount of $20,000, which results in a Capped Lien Amount
of $3,000 (See Scenario A in the chart immediately below).
Example B: If your Gross Settlement Amount is $50,000 and your Private Health Plan Provider
paid $10,000 for your medical care related to YAZ, the $10,000 lien amount will be reduced by
50% to $5,000 (Adjusted Lien Amount). The Adjusted Lien Amount will then be capped at
only 15% of the total Gross Settlement Amount of $50,000, which results in a Capped Lien
Amount of $7,500. Note that in this example the Capped Lien Amount of $7,500 is more than
the Adjusted Lien Amount of $5,000. In this example, the maximum amount you must
reimburse will be the Adjusted Lien Amount of $5,000. (See Scenario B in the chart
immediately below).
Example A Example B
Gross Settlement Amount $20,000 $50,000
Injury-Related Lien Amount $10,000 $10,000
Adjusted Lien Amount (50% reduction) $5,000 $5,000
Capped Lien Amount $3,000 $7,500
Amount You Must Reimburse $3,000 $5,000
These reductions and caps provide a great benefit to Claimants by substantially reducing the
Claimant’s reimbursement obligation. Without these reductions and caps, your Private
Health Plan Provider(s) may be entitled to recover the entire amount of its lien from your
Settlement Payment, even if that results in the Private Health Plan Provider receiving most or
all of your net Settlement Payment. Participation in the Voluntary YAZ Private Lien Resolution
Program eliminates this risk to Claimants whose YAZ-related medical expenses were paid by a
participating Private Health Plan Provider.
In addition to the reductions and caps explained above, a further benefit of the program is a cap
at 20% cap of Gross Settlement Amount of the Private Health Plan Provider lien when a claimant
has also has a Federal Medicare (Parts A, B, C or D), Medicaid, Tricare, VA, etc. In practice, if
a Claimant has a reimbursement obligation to any of the aforementioned governmental insurance
programs that equals or exceeds 20% of Gross Settlement Amount then a Private Health Plan
Provider lien will be reduced to $0.00.
Example A: If your Gross Settlement Amount is $50,000 and Medicare A&B paid $2,500 and
Medicaid paid $2,500 (total government repayment obligation of $5,000) and the Private Health
Plan Provider paid $15,000. Because you must pay $5,000 for government repayment
obligations the Private Health Provider Plan cannot recover more than $5,000 (20% of Gross
Settlement Amount is $10,000 minus $5,000).
Example B: If your Gross Settlement Amount is $50,000 and Medicare A&B paid $2,500 and
Medicaid paid $8,000 (total government repayment obligation of $10,500) and the Private Health
Plan Provider paid $15,000. Because you must pay $10,500 for government repayment
obligations the Private Health Provider Plan recovers $0. (20% of Gross Settlement Amount is
$10,000 and government repayment exceeds this amount).
Example C: If your Gross Settlement Amount is $50,000 and Medicare A&B paid $0.00 and
Medicaid paid $0.00 (total government repayment obligation of $0) and the Private Health Plan
Provider paid $15,000. Because there is no government repayment obligation the total amount
you must reimburse the Private Health Plan Provider is $7,500 (20% of Gross Settlement
Amount not applicable because no government repayment; standard cap of 15% applies-
$7,500).
Example A Example B Example C
Gross Settlement Amount $50,000 $50,000 $50,000
20% Cap Amount $10,000 $10,000 $10,000
Gov’t Insurance Repayment $5,000 $10,500 $0.00
Injury Related Lien Amount $15,000 $15,000 $15,000
Amount You Must Reimburse Your
Private Health Plan Provider
$5,000 $0 $7,500
State Laws – If at the time of your YAZ-related injury, you lived in any of the following states,
GRG will determine whether or not any state Anti-Subrogation Laws or Non-Equity Rules
would apply that might eliminate your obligation to certain Private Health Insurance Providers.
These states with Anti-Subrogation Laws are: Arizona, Connecticut, Kansas, Missouri, New
Jersey, North Carolina, New York and Virginia. These states with Non-Equity Rules are:
Illinois, Louisiana, Maine, Michigan, New Hampshire, Ohio and South Carolina.
Direct Payment – If you participate in this Voluntary YAZ Private Lien Resolution Program,
your final lien obligation will be paid directly to your Private Health Plan Provider(s) out of your
Settlement Payment. The remainder of your settlement monies will then be disbursed to you by
your attorneys (after attorneys’ fees and expenses, and any other liens are deducted). You will
not have to do anything to ensure payment of the final lien obligation amount to your Private
Health Plan Provider(s). Once your lien is resolved, the Garretson Resolution Group will
provide you a statement showing your final Private Health Plan Provider lien obligation amount
and confirming that payment has been made to your Private Health Plan Provider(s).
Accordingly, while the Program is carried out, a portion of your Gross Settlement Amount will
be withheld. One of two scenarios will occur: 1) your final Private Health Plan Provider lien
obligation amount plus the $200 administrative fee described below will be held back; or 2) if
the Garretson Resolution Group has not yet finalized your lien obligation, the applicable Capped
Lien Amount described above, plus the $200 administrative fee described below, will be held
back while the Garretson Resolution Group works to finalize the precise amount of your lien
obligation. Once the final amount of your lien is known, the Garretson Resolution Group will
promptly notify you and ensure that you are refunded any monies in excess of that amount was
temporarily held back.
Administrative Expense – The minimum Administrative Expense for a Claimant to participate
in this Voluntary YAZ Private Lien Resolution Program is $75.00 that will be paid to the
Garretson Resolution Group. If a Claimant is determined to have a lien and it is resolved
through the Private Lien Resolution Program, then an additional fee of $125.00 will be due from
the Claimant. However, if a lien is not found through the Program, then no additional funds will
be due from the Claimant. Your Private Health Plan Provider(s) will also pay a $200.00 fee if
you participate in this program and a lien is resolved.
Multiple Private Health Plan Providers - In the event that you received YAZ-related medical
benefits from multiple participating Private Health Plan Providers, the Lien Reductions and Caps
described above would apply to all Private Health Plan liens. In other words, no more than
17.5% of your gross settlement (20% if the aggregate cap applies) would be subject to Private
Health Plan liens regardless of the number of liens. Also you would pay only a single
administrative fee of $200.00 to participate in the Lien Resolution Program.
Confidentiality – If you elect to participate in this Program, the Garretson Resolution Group
will be required to exchange certain information with the participating Private Health Plan
Provider, including information regarding your claimed YAZ-related injury, certain other
Medical Information, and your Social Security Number. Other than for the purposes described in
this document and the attachments described below, the Garretson Resolution Group will hold
your private information in the strictest confidence.
BAYER Holdback - Under the terms of its Master Settlement Agreement BAYER has the right
to hold back funds it deems appropriate to cover the Claimants' responsibilities to pay lien
claims.
V. What If I Don’t Participate?
As explained above, participation in the Voluntary YAZ Private Lien Resolution Program is
entirely voluntary. You are free to elect to not participate. At the present time, however, the
defendant BAYER is refusing to authorize the release of 30% of settlement funds to
Claimants who do not choose to participate in this Program. BAYER is concerned that it
can ultimately be held liable by the Private Health Plan Providers for Claimants’ repayment
obligations. The Private Health Plan Providers participating in the Program have agreed to
absolve BAYER from any potential liability for the release of settlement funds to Claimants who
choose to participate in the Program. Thus, if you participate in the YAZ Private Lien
Resolution Program, this withheld amount will be used to pay, pursuant to the Program’s terms,
any private liens you may have, with any excess to be released to you. If you do not participate,
according to the terms of the settlement agreement and release between settling Claimants and
Bayer, BAYER will not release any portion of these funds to you until you can provide proof
that you have satisfied any potential Private Health Plan Provider claims against your YAZ-
related Settlement or 2 years elapse without Bayer being made aware of a lien interest.
If you choose not to participate in the Voluntary YAZ Private Lien Resolution Program, your
Private Health Plan Provider may never identify you as the recipient of a YAZ settlement, and
they may never contact you seeking the repayment of any YAZ-related medical expenses.
However, this does not mean that they will forfeit any contractual right of reimbursement they
may have against those who choose not to participate. Further, your Private Health Plan
Provider may identify you through their own efforts and contact you directly to resolve any liens
it may have against your YAZ settlement proceeds, pursuant to the terms of your individual
health insurance policy. You will then be responsible for resolving any such liens through your
own efforts. Importantly, those Participating Private Health Plan Providers have stated that they
will not offer the reductions and caps discussed above that they have agreed to provide under this
Voluntary YAZ Private Lien Resolution Program. This means that if you choose not to
participate, your eventual repayment obligation for your Private Health Plan Provider could
ultimately be larger than it would be if you participated in the voluntary Program.
VI. What Do I Need To Do Next?
If you would like to participate in the Voluntary YAZ Private Lien Resolution Program as
described above, you must sign and return both the attached “Notice of YAZ Private Lien
Resolution Program Offer and Acceptance” and the “Authorization for Use and Disclosure of
Protected Health Information” immediately to the address listed below. It is extremely
important that you FULLY complete the necessary fields on the “YAZ Private Lien
Resolution Program Offer and Acceptance” to include Name, Social Security Number,
Plan Name, Plan ID (also known as Member #), and then sign the bottom. Failure to fully
complete the “YAZ Private Lien Resolution Program Offer and Acceptance” could prevent
your healthcare lien from being resolved through the YAZ Private Lien Resolution
Program.
Garretson Resolution Group, Inc
P.O. Box 12540
Charlotte, NC 28220
Phone: (877) 774-1130
YAZ Exhibit 1: PLRP Participating Plan List
Participating Plan Name: Date Added:
Aetna, Inc.
AEI\BCBS PPO (Meritain Health, subsidiary of Aetna) 11/30/2012
AMERIGROUP
Alliance PPO (UnitedHealth Group, Inc.) 11/30/2012
Allied Benefit Systems (Cigna) 1/16/2013
Altius Health Administration (Coventry) 1/16/2013
American Medical Security (UnitedHealth Group, Inc.) 11/30/2012
AmeriChoice (UnitedHealth Group) 1/16/2013
Anthem (Anthem BCBS/Wellpoint)
Arkansas BCBS
Assurant Health
AvMed, Inc.
BCBS Alaska (part of Premera) 1/16/2013
BCBS Alliance Choice (Anthem) 11/30/2012
BCBS Association (BCBS Federal)
BCBS Arkansas (Health Advantage)
BCBS Blue Advantage HMO (WellPoint/Anthem or BCBS IL) 11/30/2012
BCBS Blue Choice PPO (part of BCBS TX) 1/16/2013
BCBS Colorado
BCBS Connecticut
BCBS Delaware
BCBS Georgia
BCBS Kansas City
BCBS Kentucky
BCBS Florida (Florida Blue) 12/13/2012
BCBS Hawaii
BCBS Illinois
BCBS Indiana
BCBS Lumenos (WellPoint/Anthem) 11/30/2012
BCBS Maine
BCBS Missouri
BCBS Nebraska
BCBS Nevada
BCBS New Hampshire
BCSB New Mexico
BCBS North Carolina
BCBS North Dakota (Noridian)
BCBS of Western NY (HealthNow NY) 11/30/2012
BCBS Ohio
BCSB Oklahoma
Participating Plan Name: Date Added:
BCBS Preferred Care Blue
BCBS Premera 11/30/2012
BCBS Sprint (part of BCBS Illinois) 1/16/2013
BCBS State Health Plan (BCBS NC) 11/30/2012
BCBS Texas (except for its State of Texas plan)
BCBS TRS-Activecare (part of BCBS Texas) 1/16/2013
BCBS UT Select PPO (part of BCBS Texas) 1/16/2013
BCBS Vermont
BCBS Virginia
BCBS Wisconsin
Blue Cross of California
Blue Cross Prudent Buyer (Wellpoint) 1/16/2013
Blue Shield of California
Blue Shield of NE NY (part of HealthNow NY) 1/16/2013
CareFirst, Inc. (Care First Blue Choice)
Cariten (Humana)
Choice Plus (UnitedHealth Group) 1/16/2013
CIGNA HealthCare, Inc.
Concordia Health Plan (Cigna) 1/16/2013
Coventry Health 1/3/2013
EHP Classic (Johns Hopkins Healthcare) 11/30/2012
EmblemHealth, Inc.
Empire BCBS (BCBS Empire New York)
Exxon Mobil Med Plan Aetna POS II (Aetna) 11/30/2012
First Health Coventry Health Care (Coventry) 1/3/2012
Fortis (Assurant Health) 11/30/2012
GEHA 11/30/2012
Great West Healthcare (Cigna)
Group Health Cooperative (Including KPS)
Group Health Inc. (GHI)
Government Employees Health Assoc. (GEHA)
Harvard Pilgrim Health Care, Inc.
Hawaii Medical Service Association
Health Advantage BCBS POS (part of Arkansas BCBS) 1/16/2013
Health America (Coventry) 1/3/2013
Health Assurance (Coventry) 1/3/2013
Health Care Service Corporation
Health Insurance Plan of Greater New York (HIP)
Health Net, Inc.
Healthlink (Wellpoint) 1/16/2013
HealthNow New York, Inc.
Participating Plan Name: Date Added:
HealthPartners, Inc.
Health Plan of Nevada (UnitedHealth Group, Inc.) 11/30/2012
HIP Plan of New York (Emblem) 11/30/2012
HMO Colorado (Wellpoint) 11/30/2012
HMSA/BCBS (BCBS Hawaii) 11/30/2012
Humana, Inc. IBA Health Plan Dual Select (United HealthCare employer group) 11/30/2012
IND Keystone Flexible Choice (Wellpoint) 1/16/2013
John Alden Life Insurance Co.
Johns Hopkins Healthcare
Kanawha (KHS) (Humana) 11/30/2012
Lifewise Health Plan of Washington (Premera) 11/30/2012
MAMSI (UnitedHealth Group) 1/16/2013
Medical Mutual of Ohio (MMOH) 11/30/2012
Meritain Health (Aetna)
One Net PPO (UnitedHealth Group, Inc.) 11/30/2012
Oxford Health Plan
Pacificare (UnitedHealth Group) 1/16/2013
Passport Health Plus 11/30/2012
PersonalCare Insurance (Coventry) 1/3/2013
Preferred Health Systems (Coventry) 1/3/2013
Preferred One (WellCare) 1/16/2013
Premera 11/30/2012
Priority Health
Premera, Inc.
Quality Net Care Care First BC/BS (CareFirst) 11/30/2012
Sagamore Health Network (CIGNA) 11/30/2012
Sierra Choice (now UnitedHealth Group, Inc.) 11/30/2012
Starbridge (Cigna)
Time Insurance Co.
Tufts Associated Health Plans, Inc.
Tulane University (UnitedHealth Group) 1/16/2013
Unicare (WellPoint)
Unison (UnitedHealth Group) 1/16/2013
UnitedHealth Group, Inc.
Union Security Insurance Co.
Verizon
Vytra (HIP and part of Emblem) 11/30/2012
WellCare Health Plans
Wellpoint
YAZ PRIVATE LIEN RESOLUTION PROGRAM
OFFER AND ACCEPTANCE
I have read and understand the document titled “Voluntary YAZ Private Lien Resolution Program, Claimant Information”
which explains the offer of the YAZ Private Lien Resolution Program. Having been fully informed of the offer, I elect to
participate in the YAZ Lien Resolution Program according to the terms and conditions outlined in that document.
A. CLAIMANT INFORMATION
PARTICIPATING CLAIMANT
INFORMATION
INFORMATION OF INDIVIDUAL WHO TOOK YAZ
IF NOT THE SAME AS THE PARICIPATING
CLAIMANT
Last Name Last Name
First Name First Name
SSN___-___-____ Date of Birth SSN___-___-____ Date of Birth
ADDRESS OF THE INDIVIDUAL WHO TOOK YAZ AT THE TIME OF THE INJURY-RELATED MEDICAL TREATMENT
Address
City State Zip Code
Check the appropriate box that applies to you (check only one):
I am an adult claiming YAZ-related injuries and signing for myself.
I am the Parent or Legal Representative of a disabled adult or a minor who claims YAZ-related injuries.
I am the Authorized Representative of a deceased individual who claims YAZ-related injuries.
If checked, please indicate date of death: _________________________
B. PRIVATE HEALTH INSURANCE COVERAGE
Provide the following additional information. Identify each of the healthcare providers or insurers that you believe
may have paid in any way for care related to your YAZ-related injuries since the first date of your YAZ injury through
the date of settlement. Be as specific as possible. If you have a copy of the applicable health insurance card, please
enclose a copy of that card as well.
B.1. Private Health Insurance Plan(s)
Plan
Name
Member/Plan
ID #
Employer
Name
Plan
Name
Member/Plan
ID #
Employer
Name
Plan
Name
Member/Plan
ID #
Employer
Name
Plan
Name
Member/Plan
ID #
Employer
Name
If you have received correspondence from a Private Health Insurance Provider(s) inquiring about your YAZ
settlement, attach copies of the correspondence and return them with this questionnaire.
C. RETURNING THIS FORM
Please return this Form and the “Authorization to Disclose Health Information Form” and any enclosures at your
earliest convenience and submit the materials to:
Garretson Resolution Group
P.O. Box 12540
Charlotte, NC 28220
Signature By:____________________________ Date _____/___/______
Authorization for Use and Disclosure of Protected Health Information
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (45 C.F.R. §164.508) To: Medicare Advantage Health Plans, Private Health Insurance Commercial Plans, and Recovery Contractors Re: _____________________________________________________ (Name of YAZ Claimant) Date of Birth_______________ Purpose: This document will authorize the following person(s)/entity to represent me for purposes of resolving subrogation and/or reimbursement interests/healthcare liens, if any, in my personal injury claim if any, in my personal injury claim relating to the Yaz settlement to which I am a participant. The entities and persons named below are authorized to request and receive from you any and all information related to this claim, and discuss, negotiate, and ultimately resolve this claim on my behalf. This authorization also applies to review and access to online websites containing my Protected Health Information (defined below), including but not limited to Mymedicare.gov. Information to be Disclosed: Healthcare lien/claim information, including but not limited to diagnosis and other procedural codes, as well as medical records, whether electronic or otherwise, regarding enrollment status, and/or any payments made, or medical care performed or paid for by the healthcare lien/claim holder relating to the injury-related charges for the period beginning with the date of incident (“Protected Health Information”). Person(s)/Entity Authorized to Receive and Use Protected Health Information: The Garretson Resolution Group, its agents, employees, affiliates, subsidiaries, or representatives (“GRG”). Mailing Address: Garretson Resolution Group 2115 Rexford Road, 4th Floor Charlotte, NC 28211 I hereby direct any healthcare lien/claim holder, its contract representative and/or the plan/claims administrator (the “Disclosing Party”) to release my Protected Health Information, described above, to GRG. I understand that GRG may re-disclose this information in its efforts to resolve my healthcare liens/claims. Furthermore, I understand that my Protected Health Information will no longer be protected by Federal privacy regulations. Therefore, I release the Disclosing Party from all liability arising from the disclosure of my Protected Health Information under this Authorization. Right to Revoke: I understand that I am entitled to inspect the terms of this Authorization, and I may request and receive a copy of the same if the Disclosing Party requested this Authorization. I understand that I may inspect or request copies of my Protected Health Information disclosed by this Authorization. I understand that I may revoke this Authorization by notifying the Disclosing Party or authorized entities in writing, knowing that previously disclosed information would not be subject to my revocation request. I understand refusal to authorize disclosure of my Protected Health Information will have no effect on enrollment, coverage, or the amount paid, or to be paid, for the health services I receive. This authorization will expire two (2) years from the date following the resolution of my healthcare lien/claim, and may be signed via electronic signature, facsimile signature, or original signature all of which will be legally binding as if it was the original signature. _______________________________ _________________________________________ __________ Claimant/Injured Party Signature Print Name Date OR _______________________________ _________________________________________ __________ Personal Representative Signature Print Name, and Title (based on authority to act) Date (i.e., guardianship/conservatorship letters of authority, powers of attorney, etc. attached)