Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_16-md-02691/USCOURTS-cand-3_16-md-02691-30/pdf.json

Nature of Suit Code: 367
Nature of Suit: TORTS - Personal Injury - Health Care/Pharmaceutical Personal Injury/Product Liability
Cause of Action: 28:1332 Diversity-Personal Injury

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Case No. 16-md-02691-RS – Order Concerning Plaintiff Fact Sheets, Responsive Documents, and 

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UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF CALIFORNIA 

(SAN FRANCISCO DIVISION) 

IN RE: VIAGRA (SILDENAFIL CITRATE) 

AND CIALIS (TADALAFIL) PRODUCTS 

LIABILITY LITIGATION

Case No. 16-md-02691-RS 

MDL No. 2691

This Document Relates to: 

ALL ACTIONS 

[JOINT PROPOSED] PRETRIAL ORDER 

NO. 15: PLAINTIFF FACT SHEETS, 

RESPONSIVE DOCUMENTS AND 

AUTHORIZATIONS 

This Order concerns the completion and execution of Plaintiff Fact Sheets, the initial production 

of documents by Plaintiffs, and the execution of related Authorizations for the release of records. The 

Parties agree that the use of such discovery devices will assist in furthering the proceedings. 

Accordingly, each Plaintiff shall prepare and execute Plaintiff Fact Sheet(s), shall produce documents 

and shall execute Authorizations in accordance with this Order. 

1. Scope of Order. This Order governs the completion and execution of Plaintiff Fact 

Sheets 

(“PFS”), initial production of documents, and the execution of Authorizations for the release of records 

to be completed by Plaintiffs. This Order shall govern the cases: (1) transferred to this Court by the 

Judicial Panel on Multidistrict Litigation (“JPML”), pursuant to its Order(s) of April 7, 2016 and 

December 7, 2016; (2) transferred to this Court by the JPML pursuant to Rule 7.4 of the Rules of 

Procedure of that Panel; or (3) directly filed in this Court, transferred or properly removed to this Court. 

This Order is binding on all parties and their counsel in all cases currently pending or subsequently 

made a part of these MDL Proceedings and shall govern each case in the proceedings. 

 Nothing in the PFS shall be deemed to limit the scope of inquiry at depositions or the 

admissibility of evidence at trial. The scope of inquiry at depositions shall remain governed by 

the Federal Rules of Civil Procedure. The admissibility of information provided in responding to 

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the PFS shall be governed by the Federal Rules, and no objections are waived by virtue of any 

PFS response.

2. Service of PFSs, Responsive Documents and Authorizations. Each Plaintiff shall 

complete and serve upon Defendants a PFS, in the form attached as Exhibit 1, the documents requested 

in Section VIII of the PFS (“the Responsive Documents”), and the relevant Authorizations for the 

release of records in the forms attached as Exhibits 2–8 (“the Authorizations”). Plaintiffs shall serve the 

PFSs, the Responsive Documents and the Authorizations, on the schedule set forth in paragraph 5 of this 

Order, in a manner to be set forth in a subsequent order.

3. Signature of PFS and Amendments by Plaintiff(s). All responses in a PFS or an 

amendment thereto are binding on the Plaintiff(s) as if they were contained in responses to 

interrogatories, and must be supplemented according to Federal Rule of Civil Procedure 26(e). Each 

PFS and amendment thereto shall be signed and dated by the Plaintiff or, if the Plaintiff is incapacitated, 

the proper legally appointed Plaintiff representative, under penalty of perjury. 

4. Execution and Use of Authorizations.

a. Execution of Authorizations Generally. Plaintiffs shall either (1) provide 

individual executed Authorizations for providers and facilities identified in the PFS or (2) date and sign 

the Authorizations without setting forth the identity of the applicable custodian of the records or 

provider of care (these are referred to herein as “blank” Authorizations). Plaintiffs who provide 

individual executed Authorizations for providers and facilities identified in the PFS, instead of blank 

Authorizations, shall in addition provide to Plaintiffs’ counsel, at the time that Plaintiffs’ completed PFS 

is served, blank Authorizations sufficient in number for later potential use as set forth in paragraph 4.c. 

herein, so that Plaintiffs’ counsel may meet the response time obligations set forth in that section.

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b. Authorizations to be Provided. 

i. Medical Authorizations. Each individual Plaintiff shall serve originals of 

the “Limited Authorization to Disclose Health Information” attached as Exhibit 2 for each individual 

healthcare provider identified in the PFS, or a blank authorization. If a Plaintiff is asserting a claim for 

psychological injury or has identified a mental health provider or counselor on his or her PFS in 

response to relevant questions, such Plaintiff shall also complete the Authorization attached as Exhibit 3 

for the specific providers identified in the PFS. If a Plaintiff is not asserting a claim for psychological 

injury, Plaintiff does not need to complete the Authorization attached as Exhibit 3. 

ii. Employment Authorizations. Each individual Plaintiff who has been 

employed at any time from 10 years prior to melanoma diagnosis to present and is also making a claim 

for lost wages shall execute the Authorization for the release of employment records, in the form 

attached as Exhibit 4. 

iii. Insurance Authorizations. Each individual Plaintiff who has had health 

insurance in the 5 years prior to the diagnosis with melanoma to the present shall execute an 

Authorization for the release of insurance records, in the form attached as Exhibit 5 for each effective 

policy. If the Plaintiff has been covered by Medicare at any time during the 5 years prior to the 

diagnosis with melanoma to the present, Plaintiff shall also complete the Authorization for the release of 

Medicare records, in the form attached as Exhibit 6. 

iv. Workers’ Compensation and Disability Authorizations. If a Plaintiff 

has filed for workers’ compensation or disability benefits, such Plaintiff shall execute the Authorization 

for the release of workers’ compensation records, in the form attached as Exhibit 7, and/or the 

Authorization for the release of disability records, in the form attached as Exhibit 8, as applicable. If a 

Plaintiff has not filed for either workers’ compensation or disability, that Plaintiff need not complete 

either Authorization. 

v. Obligation to Cooperate by Providing Additional Authorizations. If a 

custodian of records who was listed in the PFS, or who was identified to Plaintiff’s Counsel pursuant to 

the procedures set forth in Section 4.c.ii below, will not accept the authorizations Plaintiff has submitted, 

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Plaintiff will cooperate with Defendants and provide the necessary authorization(s) for identified 

providers and facilities. 

c. Defendants’ Use of Authorizations. 

i. Records Custodians Listed in the PFS. Defendants may use the 

provided Authorizations to obtain records from the particular custodians identified on the 

Authorizations, or from any custodian of records listed in the PFS if a blank Authorization was provided 

by Plaintiff, without further notice to Plaintiff’s counsel.

ii. Records Custodians Not Listed in the PFS. For any custodian of 

records not listed in the PFS, Defendants may use the blank Authorizations (if provided by Plaintiff) to 

obtain records by providing Plaintiffs’ Counsel notice of its intent to do so via email fourteen (14) days 

before sending the Authorization to the custodian of record (“the notice period”). If Plaintiff’s counsel 

fails to object within the notice period, Defendants may use the Authorization to request the records 

from the source identified in the notice. If Plaintiff’s counsel objects to the use of the Authorization to 

obtain records from the source identified in the notice within the notice period, Plaintiff’s counsel and 

Defendants’ counsel shall meet and confer in an attempt to resolve the objection. If counsel are unable 

to resolve the objection, Plaintiff shall file a motion for a protective order within twenty-eight (28) days 

of the Defendants’ notice of intent to use the Authorization. 

For any custodian of records not listed in the PFS, if blank Authorizations have 

not already been provided by Plaintiff, Defendants may request that Plaintiff’s counsel complete an 

Authorization, either blank or fully executed for the requested custodian, so that Defendants may obtain 

records from that custodian. Plaintiffs’ counsel must provide such authorizations within fourteen (14) 

days of the written request. If Plaintiffs’ counsel objects to the use of the Authorization to obtain records 

from the source identified in the request, Plaintiffs’ counsel must assert that objection within fourteen 

(14) days. Following the 14-day period, if Plaintiffs’ counsel objects or has not responded, Plaintiffs’ 

counsel and Defendants’ counsel shall meet and confer in an attempt to resolve the objection. 

Defendants’ counsel shall also notify Plaintiffs’ designated PSC fact sheet counsel. If counsel are unable 

to resolve the objection, or if Plaintiffs’ counsel does not respond to Defendants’ attempt to meet and 

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confer, Defendants may file a motion to compel Plaintiffs’ counsel shall have fourteen (14) days to file 

any opposition. 

d. Production of Records Obtained by Authorizations. Defendants’ counsel shall 

make records received pursuant to the Authorizations available to Plaintiff’s counsel at Plaintiff’s 

request and at cost to Plaintiff, in a manner to be set forth in a subsequent order

5. Deadline for PFSs, Authorizations, and Responsive Documents.

a. Northern District of California Resident Cases Currently in MDL 

Proceedings. All Plaintiffs who reside within the Northern District of California and whose cases are 

currently part of these MDL Proceedings must serve Defendants with PFSs, Responsive Documents and 

Authorizations within or not later than one hundred twenty (120) days of entry of this order. 

b. Remaining Cases Pending in MDL Proceedings. All Plaintiffs whose cases are 

currently part of these MDL Proceedings, and who are not included among the Plaintiffs discussed in 

paragraph a, must serve Defendants with PFSs, Responsive Documents and Authorizations within or not 

later than one hundred fifty(150) days of entry of this order. 

 c. Cases Later Made Part of MDL Proceedings. For any Plaintiff whose case is 

not currently part of these MDL Proceedings as of the date of this Order, but whose case is later filed in, 

transferred to, removed to, or reassigned to this Court and thereby made part of these MDL Proceedings, 

such Plaintiffs must serve Defendants with a complete and verified PFS, Responsive Documents, and 

completed Authorizations within the following time limits: (1) if Plaintiff’s case is filed directly in the 

Northern District of California, within one hundred twenty (120) days from the date filed; or (2) if 

Plaintiff’s case is filed outside the Northern District of California and later transferred or removed to this 

Court, within thirty (30) days from the date the short form complaint is filed in this Court.. 

6. Grace Period for Delinquent Plaintiffs. Plaintiffs who fail to provide a complete and 

verified PFS, Responsive Documents, and execute Authorizations within the time periods set forth above 

shall be given notice by e-mail from Defendants’ Counsel of all deficiencies, copying Plaintiffs’ 

designated PSC fact sheet counsel, and shall be given thirty (30) additional days to cure such deficiency.

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If a Plaintiff does not cure the deficiency within that period of time, Defendants may move the 

Court for an Order dismissing such Plaintiff’s Complaint without prejudice. Plaintiff shall have thirty 

(30) days from the date of Defendants’ motion to file a response either (1) certifying that Plaintiff has 

served upon Defendants, and Defendants have received, a completed PFS, and attaching appropriate 

documentation of receipt, or (2) opposing Defendants’ motion. If a Plaintiff timely files such a 

response, his or her claims shall not be dismissed. 

Upon entry of an Order of Dismissal without Prejudice, Plaintiff shall have thirty (30) days to 

serve Defendants with a completed PFS or move to vacate the dismissal. If Plaintiff fails to serve 

Defendants with a completed PFS or move to vacate the dismissal within thirty (30) days, the Order 

will, upon Defendants’ motion, be converted into an Order of Dismissal with Prejudice. 

7. Additional Discovery Permitted. Defendants’ use of the PFS, Responsive Documents, 

and Authorizations shall be without prejudice to Defendants’ right to serve additional discovery at a 

later time, to be determined according to this Court’s subsequent orders. 

SO ORDERED. 

Dated: ____________________________________ 

 THE HONORABLE RICHARD SEEBORG 

 UNITED STATES DISTRICT JUDGE 

11/30/18

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EXHIBIT 1 

Plaintiff Fact Sheet

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1 DC: 6815120-1 

IN THE UNITED STATES DISTRICT COURT 

FOR THE NORTHERN DISTRICT OF CALIFORNIA 

MDL No. 2691

 In Re: Viagra (Sildenafil Citrate) and Cialis (Tadalafil) Products Liability Litigation 

______________________________________________________________________________

Instructions

Please answer every question to the best of your knowledge. In completing this Plaintiff Fact 

Sheet, you are under oath and must provide information that is true and correct to the best of 

your knowledge. If you cannot recall all the details requested, please provide as much 

information as you can or otherwise indicate that you cannot recall. You must supplement your 

responses if you learn that they are incomplete or incorrect in any material respect. For each 

question where the space provided does not allow for a complete answer, please attach additional 

sheets so that all answers are complete. 

If you are asked to identify a person (such as doctors or witnesses), please provide the name and 

last-known address and telephone number. 

Definitions

PLAINTIFF, YOU OR YOUR: The individual who allegedly took Viagra, Revatio, Cialis and/or 

Adcirca. 

VIAGRA/REVATIO: These two drugs are part of a class of drugs known as PDE5 inhibitors. The 

active ingredient in both is sildenafil and the manufacturer is Pfizer Inc. 

CIALIS/ADCIRCA: These two drugs are part of a class of drugs known as PDE5 inhibitors. The 

active ingredient in both is tadalafil and the manufacturer is Eli Lilly & Co. 

TREATING HEALTHCARE PROVIDERS: Any provider of healthcare, including but not necessarily 

limited to physicians, general practitioners, medical specialists, medical doctors, surgeons, 

plastic surgeons, nurses, nurse practitioners, physician assistants, rehabilitation specialists, 

physical therapists, occupational therapists, counselors and pharmacists. 

SERIOUS ILLNESS: A serious illness is a condition that involves one or more of the following: 

hospital care; a period of incapacity lasting three or more consecutive days; pregnancy; chronic 

conditions requiring continued or repeated treatments; permanent/long-term conditions requiring 

supervision and/or multiple treatments for a non-chronic condition. 

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VIII. DOCUMENTS 

A. Please indicate if any of the following documents and things are currently in your 

possession, custody or control or in the possession, custody, or control of your 

lawyers, and if so, please attach a copy to this Fact Sheet: 

1. Records of treating healthcare providers, hospitals, pharmacies, insurance and 

other healthcare providers identified in response to this fact sheet.

 Yes _____ No _____ 

 2. Deceased person’s death certificate (if applicable).

 Yes _____ No _____ 

 3. Report of autopsy of deceased person (if applicable). 

 Yes _____ No _____ 

B. Authorizations - Please sign and attach to this Fact Sheet the authorizations for the 

release of records appended hereto. 

C. Documents in your possession - If you have any of the following materials in your 

custody, control or possession or in the possession, custody or control of your lawyers, 

please attach a copy to this Fact Sheet. This does not include privileged materials. If you 

do not have documents in your current possession to produce, please check the N/A box.

This section recognizes that discovery is ongoing and shall be supplemented as new 

information becomes available.

1. If you have been the claimant or subject of any worker’s compensation, Social 

Security or other disability proceeding, all documents relating to such proceeding. 

N/A 

2. Copies of the entire packaging, including the bottle, box, and label for the Viagra, 

Revatio, Cialis and/or Adcirca you allege caused your injury and any remaining 

medication. (Plaintiff must maintain the originals of the items requested in this 

subpart.)

N/A 

3. All written statements obtained from or given by any person having knowledge of 

facts relevant to the subject of this litigation. (Please do not create a new 

document to respond to this request.) 

N/A 

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4. All documents relating to your purchase of Viagra, Revatio, Cialis and/or 

Adcirca, including, but not limited to, receipts, prescriptions, or records of 

purchase. 

N/A 

5. All documents in your possession which you believe were provided to you (not to 

your lawyer) by Defendant(s). 

N/A 

6. All photographs, drawings, slides or videos from two years prior to the diagnosis 

of melanoma until the present relating to Viagra, Revatio, Cialis and/or Adcirca, 

and/or the melanoma you allege Viagra, Revatio, Cialis and/or Adcirca caused. 

N/A 

7. All entries in journals, diaries, notes, letters, emails, or other documents written 

by you relating to erectile dysfunction, pulmonary arterial hypertension, benign 

prostastic hyperplasia, your use of Viagra, Revatio, Cialis and/or Adcirca, and/or 

the injuries you allege Viagra, Revatio, Cialis and/or Adcirca caused. 

N/A 

8. All documents you received from your healthcare provider(s) relating to erectile 

dysfunction, pulmonary arterial hypertension, benign prostastic hyperplasia, your 

use of Viagra, Revatio, Cialis and/or Adcirca, and/or the injuries you allege 

Viagra, Revatio, Cialis and/or Adcirca caused. 

N/A 

9. All documents (including electronic data) relating to any web sites you have 

viewed, chat rooms, web logs (or “blogs”), electronic mail, or other Internet 

activity in which you have engaged related to your use of Viagra, Revatio, Cialis 

and/or Adcirca and/or the injuries you allege Viagra, Revatio, Cialis and/or 

Adcirca caused. 

N/A 

10. All documents relating to any communication by you to or from the Food & Drug 

Administration (“FDA”), including but not limited to on-line, telephoned, mailed, 

or faxed communications to the FDA’s MedWatch program, regarding Viagra, 

Revatio, Cialis and/or Adcirca, including the dates of such communications. 

N/A 

11. If you claim you have suffered a loss of earnings or earning capacity, your federal 

tax returns for each year you are claiming a loss. 

N/A 

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12. If you claim any loss from medical expenses, copies of all bills from any treating 

healthcare provider, hospital, pharmacy or other healthcare provider. 

N/A 

13. Copies of letters testamentary or letters of administration relating to your status as 

plaintiff (if applicable). 

N/A 

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VERIFICATION

I,_______________________, declare under penalty of perjury subject to 28 U.S.C. § 1746 that 

all of the information provided in this Plaintiff’s Fact Sheet is true, complete, and correct to the 

best of my knowledge, information, and belief, and that I have supplied all the documents 

requested in Part VIII of this Plaintiff’s Fact Sheet, to the extent that such documents are in my 

possession or in the possession of my lawyers, and that I have signed and supplied the 

authorizations attached to this Verification. 

 Further, I acknowledge that I have an obligation to supplement the above responses if I 

learn that they are in any material respect incomplete or incorrect. 

___________________________________________ ____________________ 

Signature Date 

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EXHIBIT 2 

Authorization and Release for Medical Records 

Excluding Psychiatric, Psychological and Mental Health Treatment 

Providers/Notes/Records

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LIMITED AUTHORIZATION TO DISCLOSE HEALTH INFORMATION 

(Excluding Psychiatric, Psychological, and Mental Health Treatment Notes/Records) 

(Pursuant to the Health Insurance Portability and Accountability Act “HIPAA” of 4/14/03) 

To: 

Name 

Address 

City, State and Zip Code 

Re: 

Name of Patient Date of Birth Social Security Number 

This will authorize you to furnish copies of the following records and/or information: 

* All medical records, including inpatient, outpatient, and emergency room treatment, all clinical charts, reports, documents, 

correspondence, test results, statements, questionnaires/histories, office and doctor’s handwritten notes, and records received by 

other physicians. 

* All autopsy, laboratory, histology, cytology, pathology, radiology, CT Scan, MRI, echocardiogram and catheterization reports. 

* All radiology films, mammograms, myelograms, CT scans, photographs, bone scans, 

pathology/cytology/histology/autopsy/immunohistochemistry specimens, cardiac catheterization videos/CDs/films/reels, and 

echocardiogram videos. 

* All pharmacy/prescription records including NDC numbers and drug information handouts/monographs. 

* All billing records including all statements, itemized bills, and insurance records. 

**Notwithstanding the broad scope of the above disclosure requests, the undersigned does not authorize the disclosure of notes 

or records pertaining to psychiatric, psychological, or mental health treatment or diagnosis as such terms are defined by 

HIPAA, 45 CFR §164.501.

1. To my medical provider: This authorization is being forwarded by, or on behalf of, attorneys for the defendants for the 

purpose of litigation. You are not authorized to discuss any aspect of the above-named person’s medical history, care, 

treatment, diagnosis, prognosis, information revealed by or in the medical records, or any other matter bearing on his or 

her medical or physical condition. Subject to all applicable legal objections, this restriction does not apply to discussing these 

matters at a deposition or trial.

2. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do 

so in writing and present my written revocation to the health information management department. I understand the revocation will

not apply to information that has already been released in response to this authorization. I understand the revocation will not apply 

to my insurance company when the law provides my insurer with the right to contest a claim under my policy. 

3. Unless otherwise revoked, this authorization will expire in one year. 

4. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not 

sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed as provided 

in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and 

the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, 

I can contact the releaser indicated above. 

5. A notarized signature is not required. A copy of this authorization may be used in place of an original. 

6. This authorization shall be considered as continuing in nature and is to be given full force and effect to release information of any 

of the foregoing learned or determined after the date hereof. 

7. I understand that the information in my health record may include information relating to sexually transmitted disease, 

acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). I understand that by signing this 

authorization I am agreeing that this protected information will be released. 

You are authorized to release the above records to the following representatives of defendants, who have agreed to pay reasonable

charges made by you to supply copies of such records: Litigation Management, Inc.; 6000 Parkland Boulevard; Mayfield Heights, 

OH 44124. 

Date: 

Patient/Representative Signature [Print name if not Patient] 

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EXHIBIT 3 

Authorization and Release for Mental Health Records 

To be executed ONLY if Plaintiff is asserting a claim for psychological injury or has 

identified a mental health provider or counselor on his or her PFS in response to relevant 

questions.

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LIMITED AUTHORIZATION TO DISCLOSE PSYCHIATRIC, PSYCHOLOGICAL 

AND/OR MENTAL HEALTH TREATMENT NOTES/RECORDS 

(Pursuant to the Health Insurance Portability and Accountability Act “HIPAA” of 4/14/03) 

To: 

Name 

Address 

City, State and Zip Code 

Re: 

Name of Patient Date of Birth Social Security Number 

This will authorize you to furnish copies of the following records and/or information: 

• All “psychotherapy notes”, as such term is defined by the Health Insurance Portability and Accountability Act, 45 

CFR §164.501. Under HIPAA, the term “psychotherapy notes” means notes recorded (in any medium) by a health 

care provider who is a mental health professional documenting or analyzing the contents of conversations during a 

private counseling session or a group, joint or family counseling session and that are separated from the rest of the 

individual’s record. This authorization does not authorize ex parte communication concerning same. 

1. To my medical provider: This authorization is being forwarded by, or on behalf of, attorneys for the defendants 

for the purpose of litigation. You are not authorized to discuss any aspect of the above-named person’s 

medical history, care, treatment, diagnosis, prognosis, information revealed by or in the medical records, or 

any other matter bearing on his or her medical or physical condition. Subject to all applicable legal 

objections, this restriction does not apply to discussing these matters at a deposition or trial.

2. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this 

authorization I must do so in writing and present my written revocation to the health information management 

department. I understand the revocation will not apply to information that has already been released in response to 

this authorization. I understand the revocation will not apply to my insurance company when the law provides my 

insurer with the right to contest a claim under my policy. 

3. Unless otherwise revoked, this authorization will expire in one year. 

4. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this 

authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the 

information to be used or disclosed as provided in CFR 164.524. I understand that any disclosure of information 

carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal 

confidentiality rules. If I have questions about disclosure of my health information, I can contact the releaser 

indicated above. 

5. A notarized signature is not required. A copy of this authorization may be used in place of an original. 

6. This authorization shall be considered as continuing in nature and is to be given full force and effect to release 

information of any of the foregoing learned or determined after the date hereof. 

7. I understand that the information in my health record may include information relating to sexually 

transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus 

(HIV). I understand that by signing this authorization I am agreeing that this protected information will be 

released.

You are authorized to release the above records to the following representatives of defendants, who have agreed to pay 

reasonable charges made by you to supply copies of such records: Litigation Management, Inc.; 6000 Parkland 

Boulevard; Mayfield Heights, OH 44124. 

Date: 

Patient/Representative Signature [Print name if not Patient] 

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EXHIBIT 4 

Authorization and Release of Employment Records 

To be executed ONLY for specific Employer(s) for which Plaintiff is making a wage 

loss claim.

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LIMITED AUTHORIZATION TO DISCLOSE 

EMPLOYMENT AND WAGE RECORDS 

To: 

Name of Employer 

Address

City, State and Zip Code 

I authorize the limited disclosure of my personnel file for the purpose of review and evaluation in connection 

with a legal claim; copies of all applications for employment; resumes; records of all positions held; job 

descriptions of positions held; wage and income statements and/or compensation records; wage increases 

and decreases; evaluations, reviews and job performance summaries; W-2s; and correspondence or 

memoranda regarding the undersigned. 

Name of Employee Date of Birth Social Security Number 

You are authorized to release the above records to the following representatives of defendants, who have 

agreed to pay reasonable charges made by you to supply copies of such records: Litigation Management, 

Inc.; 6000 Parkland Boulevard; Mayfield Heights, OH 44124. 

This authorization does not authorize you to disclose anything other than documents and records to anyone. 

This authorization shall be considered as continuing in nature and is to be given full force and effect to 

release information of any of the foregoing learned or determined after the date hereof. I 

I acknowledge the right to revoke this authorization by writing to you at the above referenced address. 

However, I understand that any actions already taken in reliance on this authorization cannot be reversed, 

and my revocation will not affect those actions. Any facsimile, copy or photocopy of this authorization 

shall authorize you to release the records herein with the same validity as if the original had been presented 

to you. Unless otherwise revoked, this authorization will expire in one year. 

Date: 

Employee/Guardian/Personal Representative 

Signature [Print name if not Employee] 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 34 of 49
EXHIBIT 5 

Authorization and Release for Health Insurance Records 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 35 of 49
LIMITED AUTHORIZATION FOR RELEASE OF HEALTH INSURANCE RECORDS 

(HIPAA COMPLIANT AUTHORIZATION FORM PURSUANT TO 45 CFR 164.508) 

To: 

Name 

Address

City, State and Zip Code 

This will authorize you to furnish copies of any and all insurance claims applications and benefits, and all 

medical, health, hospital, physicians, nursing or allied health professional reports, records or notes, invoices 

and bills, in your possession that pertain to the named insured identified below. 

Name of Insured Date of Birth Social Security Number 

You are authorized to release the above records to the following representatives of defendants, who have 

agreed to pay reasonable charges made by you to supply copies of such records: Litigation Management, 

Inc.; 6000 Parkland Boulevard; Mayfield Heights, OH 44124. 

This authorization does not authorize you to disclose anything other than documents and records to anyone. 

This authorization shall be considered as continuing in nature and is to be given full force and effect to 

release information of any of the foregoing learned or determined after the date hereof. It is expressly 

understood by the undersigned and you are authorized to accept a copy or photocopy of this authorization 

with the same validity as through the original had been presented to you. Unless otherwise revoked, this 

authorization will expire in one year. 

Date: 

Insured/Guardian/Personal Representative 

Signature [Print name if not Insured] 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 36 of 49
EXHIBIT 6 

Authorization and Release for Centers for Medicare and Medicaid 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 37 of 49
Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 38 of 49
If you have any questions or need additional assistance, please feel free to call us at 1-800-

MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 

Sincerely,

1-800-MEDICARE

Customer Service Representative

Encl.

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 39 of 49
Department of Health and Human Serv ices Form Approv ed 

Centers for Medicare & Medicaid Serv ices OMB No. 0938-0930 

Ex piration Date: 6/30/2021

Form CMS-10106 (Rev 06/18) 

Instructions

Information to Help You Fill Out the

“1-800-MEDICARE Authorization to Disclose Personal Health Information” Form

By law, Medicare must have your written permission (an “authorization”) to use or give out your

personal medical information for any purpose that isn't set out in the privacy notice contained in the

Medicare & You handbook. You may take back (“revoke”) your written permission at any time, except

if Medicare has already acted based on your permission.

If you want 1-800-MEDICARE to give your personal health information to someone other than you,

you need to let Medicare know in writing.

If you are requesting personal health information for a deceased beneficiary, please include a copy of 

the legal documentation which indicates your authority to make a request for information. (For

example: Executor/Executrix papers, next of kin attested by court documents with a court stamp and a 

judge's signature, a Letter of Testamentary or Administration with a court stamp and judge's signature,

or personal representative papers with a court stamp and judge's signature.) Also, please explain your

relationship to the beneficiary.

Please use this step by step instruction sheet when completing your “1-800-MEDICARE Authorization

to Disclose Personal Health Information” Form. Be sure to complete all sections of the form to ensure

timely processing.

1. Print the name of the person with Medicare.

Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card.

Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.

2. This section tells Medicare what personal health information to give out. Please check a box in

2A to indicate how much information Medicare can disclose. If you only want Medicare to

give out limited information (for example, Medicare eligibility), also check the box(es) in 2B 

that apply to the type of information you want Medicare to give out. Box 2C must be completed 

by New York Residents.

3. This section tells Medicare when to start and/or when to stop giving out your personal health

information. Check the box that applies and fill in dates, if necessary.

4. This section tells Medicare the reason for disclosure.

5. Medicare will give your personal health information to the person(s) or organization(s) you fill in

here. You may fill in more than one person or organization.

If you designate an organization, you must also identify one or more individuals in that

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 40 of 49
Department of Health and Human Serv ices Form Approv ed 

Centers for Medicare & Medicaid Serv ices OMB No. 0938-0930 

Ex piration Date: 6/30/2021

Form CMS-10106 (Rev 06/18) 

Instructions

organization to whom Medicare may disclose your personal health information.

6. The person with Medicare or personal representative must sign their name, fill in the date, and

provide the phone number and address of the person with Medicare.

If you are a personal representative of the person with Medicare, check the box, provide your

address and phone number, and attach a copy of the paperwork that shows you can act for that

person (for example, Power of Attorney).

7. Send your completed, signed authorization to Medicare at the address shown here on your

authorization form.

8. If you change your mind and don't want Medicare to give out your personal health information,

write to the address shown under number seven on the authorization form and tell Medicare.

Your letter will revoke your authorization and Medicare will no longer give out your personal

health information (except for the personal health information Medicare has already given out

based on your permission).

You should make a copy of your signed authorization for your records before mailing it to Medicare.

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 41 of 49
Department of Health and Human Serv ices Form Approv ed 

Centers for Medicare & Medicaid Serv ices OMB No. 0938-0930 

Ex piration Date: 6/30/2021

Form CMS-10106 (Rev 06/18) 

1-800-MEDICARE Authorization to Disclose Personal Health Information

Use this form if you want 1-800-MEDICARE to give your personal health information to someone 

other than you.

___________________________________ _____________________ ___________

1. Print Name

(First and last name of the person with Medicare)

Medicare Number

(Exactly as shown on the Medicare Card)

Date of Birth

(mm/dd/yyyy) 

2. Medicare will only disclose the personal health information you want disclosed.

2A: Check only one box below to tell Medicare the specific personal health information you 

want disclosed:

Limited Information (go to question 2b) 

Any Information (go to question 3) 

2B: Complete only if you selected “limited information”. Check all that apply:

Information about your Medicare eligibility

Information about your Medicare claims

Information about plan enrollment (e.g. drug or MA Plan)

Information about premium payments

Other Specific Information (please write below; for example, payment information)

2C: NY Residents Only, this section must be completed.

Please select one of the following options: (Please check only one box.)

Include all information. This includes information about alcohol and drug abuse, mental 

health treatment, and HIV.

OR

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 42 of 49
Exclude information about alcohol and drug abuse, mental health treatment, and HIV.

Department of Health and Human Serv ices Form Approv ed 

Centers for Medicare & Medicaid Serv ices OMB No. 0938-0930 

Ex piration Date: 6/30/2021

Form CMS-10106 (Rev 06/18) 

3. Check only one box below indicating how long Medicare can use this authorization to disclose

your personal health information (subject to applicable law—for example, your State may limit

how long Medicare may give out your personal health information):

Disclose my personal health information indefinitely

Disclose my personal health information for a specified period only

beginning: ____________________(mm/dd/yyyy) and ending: _________________(mm/dd/yyyy)

4. Fill in the reason for the disclosure (you may write "at my request"):

5. Fill in the name and address of the person or organization to whom you want Medicare to

disclose your personal health information. Please provide the specific name of the person for

any organization you list below. If you would like to authorize any additional individuals or

organizations, please add those to the back of this form.

Name ______________________________________________________________________ 

Address ______________________________________________________________________

Name ______________________________________________________________________ 

Address ______________________________________________________________________

Litigation Management, Inc.

6000 Parkland Boulevard, Mayfield Heights, OH 44124

This authorization is being forwarded by, or on behalf of, attorneys for the defendants for

the purpose of litigation.

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 43 of 49
Department of Health and Human Serv ices Form Approv ed 

Centers for Medicare & Medicaid Serv ices OMB No. 0938-0930 

Ex piration Date: 6/30/2021

Form CMS-10106 (Rev 06/18) 

Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except 

to the extent that Medicare has already acted based on your permission. To revoke authorization, 

send a written request to the address noted below. Your authorization or refusal to authorize disclosure 

of your personal health information will have no effect on your enrollment, eligibility for benefits, or the 

amount Medicare pays for the health services you receive.

6. I authorize 1-800-MEDICARE to disclose my personal health information listed above to

the person(s) or organization(s) I have named on this form. I understand that my

personal health information may be re-disclosed by the person(s) or organization(s) and

may no longer be protected by law.

Signature Telephone Number Date (mm/dd/yyyy)

Print the address of the person with Medicare (Street Address, City, State, and ZIP)

Check here if you are signing as a personal representative and complete below.

Please attach the appropriate documentation (for example, Power of Attorney). This only

applies if someone other than the person with Medicare signed above.

Print the Personal Representative's Address (Street Address, City, State, and ZIP)

Telephone Number of Personal Representative:

Personal Representative's Relationship to the Beneficiary:

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 44 of 49
Department of Health and Human Serv ices Form Approv ed 

Centers for Medicare & Medicaid Serv ices OMB No. 0938-0930 

Ex piration Date: 6/30/2021

Form CMS-10106 (Rev 06/18) 

7. Send the completed, signed authorization to: 

Medicare CCO, Written Authorization Dept.

PO Box 1270 

Lawrence, KS 66044 

Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except to the 

extent that Medicare has already acted based on your permission. If you would like to revoke 

authorization, send a written request to the address noted above. 

Your authorization or refusal to authorize disclosure of your personal health information will have no 

effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services 

you receive.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless it displays a valid OMB control number. The valid OMB control number for this

information collection is 0938-0930. The time required to complete this information collection is

estimated to average 15 minutes per response, including the time to review instructions, search existing

data resources, gather the data needed, and complete and review the information collection. If you have

comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please

write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, 

Baltimore, Maryland 21244-1850. 

Print Form

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 45 of 49
EXHIBIT 7 

Authorization and Release for Workers’ Compensation Records 

To be executed ONLY if you have indicated a worker’s compensation claim in the PFS 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 46 of 49
LIMITED AUTHORIZATION FOR RELEASE 

OF WORKERS’ COMPENSATION RECORDS 

(HIPAA COMPLIANT AUTHORIZATION FORM PURSUANT TO 45 CFR 164.508) 

To: 

Name 

Address

City, State and Zip Code 

This will authorize you to furnish copies of any and all workers’ compensation records of any sort for any 

workers’ compensation claims filed, including, but not limited to, statements, applications, disclosures, 

correspondence, notes, settlements, agreements, contracts or other documents, concerning: 

Name of Claimant Date of Birth Social Security Number 

You are authorized to release the above records to the following representatives of defendants, who have 

agreed to pay reasonable charges made by you to supply copies of such records: Litigation 

Management, Inc.; 6000 Parkland Boulevard; Mayfield Heights, OH 44124. 

This authorization does not authorize you to disclose anything other than documents and records to anyone. 

This authorization shall be considered as continuing in nature and is to be given full force and effect to 

release information of any of the foregoing learned or determined after the date hereof. It is expressly 

understood by the undersigned and you are authorized to accept a copy or photocopy of this authorization 

with the same validity as through the original had been presented to you. Unless otherwise revoked, this 

authorization will expire in one year. 

Date: 

Claimant/Guardian/Personal Representative 

Signature [Print name if not Claimant] 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 47 of 49
EXHIBIT 8 

Authorization and Release for Disability Claims Records

To be executed ONLY if you have indicated a disability claim in the PFS 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 48 of 49
LIMITED AUTHORIZATION FOR RELEASE OF 

DISABILITY CLAIMS RECORDS 

(HIPAA COMPLIANT AUTHORIZATION FORM PURSUANT TO 45 CFR 164.508) 

To: 

Name 

Address

City, State and Zip Code 

This will authorize you to furnish copies of any and all records of disability claims of any sort for any 

disability claim(s) filed, including, but not limited to, statements, applications, disclosures, correspondence, 

notes, settlements, agreements, contracts or other documents, concerning: 

Name of Claimant Date of Birth Social Security Number 

You are authorized to release the above records to the following representatives of defendants, who have 

agreed to pay reasonable charges made by you to supply copies of such records: Litigation Management, 

Inc.; 6000 Parkland Boulevard; Mayfield Heights, OH 44124. 

This authorization does not authorize you to disclose anything other than documents and records to anyone. 

This authorization shall be considered as continuing in nature and is to be given full force and effect to 

release information of any of the foregoing learned or determined after the date hereof. It is expressly 

understood by the undersigned and you are authorized to accept a copy or photocopy of this authorization 

with the same validity as through the original had been presented to you. Unless otherwise revoked, this 

authorization will expire in one year. 

Date: 

Claimant/Guardian/Personal Representative 

Signature [Print name if not Claimant] 

Case 3:16-md-02691-RS Document 804 Filed 11/30/18 Page 49 of 49