*By providing your e-mail address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.
You must meet the following criteria to be eligible for a payment from the Proposed Settlements:
Excluded from the Class and from the Proposed Settlements are:
Please contact the Settlement Administrator if you made purchases both with and without insurance.
Did you make Lidoderm purchases using insurance?
Provide the number of boxes (of 30 patches each) that you purchased for your own use or for the use of your family member.
Only include purchases in Arizona, California, Florida, Kansas, Maine, Massachusetts, Minnesota, Nevada, New Hampshire,
New Mexico, New York, North Carolina, North Dakota, South Dakota, Tennessee, West Virginia, or Wisconsin.
Provide the number of brand Lidoderm boxes (of 30 patches each) you purchased from August 23, 2012 through September 14, 2013 in the above-listed states.
If you had a percentage copay (for example, 20% of the prescription's cost), please fill out the below box. DO NOT FILL OUT THIS
BOX IF YOU HAD A SET DOLLAR COPAY FOR GENERIC DRUGS (for example, $20 for generics).
Provide the number of generic Lidoderm (Lidocaine patch 5%) boxes (of 30 patches each)
you purchased from September 15, 2013 through August 1, 2014 in the above-listed states.
By filling in any number in the box above. I hereby also certify that I did not have a set
dollar co-pay for generic drugs (for example, $20 for generics).
You do not need to provide any documentation at this time. However, the Claims Administrator may ask for additional proof of purchase.
I have read and am familiar with the contents of this Claim Form. I certify that the information I have set forth in this Claim
Form and in any documents attached by me are true, correct and complete to the best of my knowledge. I further certify that
I am submitting this information on behalf of myself or a Class Member for whom I serve in the capacity of an authorized
agent. I acknowledge that any false information or representations contained herein may subject me to sanctions, including
the possibility of criminal prosecution.
In the event amounts from the Settlement Fund are distributed to me and a Class Member later claims that I did not have
authority to claim and/or receive funds on that Class Member's behalf, I and my employers, affiliates, subsidiaries and all
related entities will hold the Class, counsel for the Class, Defendants, and the Claims Administrator harmless with respect to
any claims made by the Class Member.
I hereby submit to the jurisdiction of the United States District Court for the Northern District of California for all purposes
connected with this Claim Form, including resolution of disputes relating to this Claim Form.