Claim Form Test

CLAIM INFORMATION

You must attach a Louisiana Driver’s License, a State Identification card, or other documentation that shows you actually lived at this address on December 2, 2016

You must attach a time card, payroll record or similar record that shows you were actually working in the Area on December 2, 2016.

1. I am over the age of eighteen (18) and am competent to be a witness in this matter. I have personal knowledge of the facts set forth herein.

2. I understand that in reaching a settlement, the parties have considered Medicare’s interest in recovering conditional payments made for medical treatment rendered as a result of the claim that is the subject of this litigation.

3. I have provided by Social Security Number and date of birth. I understand that if I am a Medicare beneficiary and I do not provide the requested information, including a Health Insurance Clam Number, I may be violating obligations as a beneficiary to assist Medicare in coordinating benefits to pay my claim(s) correctly and promptly.

4. I hereby make the following representations and warranties in affirming that I am not eligible for Medicare:

• (a) To the best of my knowledge, I am not eligible for Medicare benefits.
• (b) I have not applied for Medicare benefits.
• (c) Medicare has made no conditional payments for any medical expense or prescription expense related to any injury related to this litigation.
• (d) I am not, nor have I ever been a Medicare beneficiary.
• (e) I am not currently receiving Social Security Disability Benefits or Railroad Retirement Benefits.
• (f) I have not applied for Social Security Disability Benefits or Railroad Retirement Benefits.
• (g) I have not been denied Social Security Disability Benefits or Railroad Retirement Benefits.
• (h) I have not appealed from a denial of Social Security Disability Benefits or Railroad Retirement Benefits.
• (i) I am not in End Stage Renal Failure.
• (j) I have not been diagnosed with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s Disease.
• (k) No liens, including but not limited to liens for medical treatment of any injury related to this litigation, by hospitals, physicians, or medical providers of any kind have been filed for the treatment of injuries sustained as related to this litigation.

5. I assume all responsibility for all liens related to the treatment of any injury related to this litigation, including those asserted by Medicare or any other entity pursuant to Medicare, Medicaid and SCHIP Extension Act and/or the Medicare Secondary Payor Act.

I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of this affidavit are true.