South Peninsula Hospital v. Xerox State Healthcare, LLC

NO. 3:15-CV-00177-JMK

United States District Court for the District of Alaska

If you received a personalized notice in the mail or via email with a Claimant ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Claimant ID exactly as it appears on your personalized Notice, (i.e. 12345678).

Claims may only be submitted online with a Claimant ID and Confirmation Code, and if you have questions please call (855) 201-9818.

IMPORTANT: All Alaska Medicaid billing providers that submitted a Medicaid claim to Alaska Medicaid for Medicaid eligible services rendered during the period from October 1, 2013 to December 31, 2016 are eligible to receive a cash settlement payment as a result of a class action settlement in the above-captioned case. To receive a cash payment from the Settlement Fund, you must complete and timely submit this Claim Form.

INSTRUCTIONS: To complete this Claim Form, please provide all requested information below, sign the Certification below, and return this Claim Form to the Settlement Administrator: (a) online at the Settlement Website; (b) by email to info@HealthProviderSettlement.com; or (c) by First-Class U.S. Mail to the following address: Health Provider Class Action, c/o Settlement Administrator, 1650 Arch Street, Suite 2210, Philadelphia, PA 19103. Please keep a copy of your completed Claim Form. YOU MUST SUBMIT THIS CLAIM FORM BY FEBRUARY 10, 2021 FOR IT TO BE CONSIDERED TIMELY.


CLAIMANT INFORMATION
* Required Fields
Note — It is your responsibility to let the Settlement Administrator know if your mailing address changes at any time before you receive a Settlement Payment.
CERTIFICATION

I declare under penalty of perjury pursuant to 28 U.S.C. ยง 1746 that the above-listed Claimant is or was an Alaska Medicaid billing provider that submitted at least one Medicaid claim to Alaska Medicaid for services rendered during the period from October 1, 2013 to December 31, 2016, and did not receive timely reimbursement(s), resulting in economic harm to the Claimant, including loss of the time use of money and/or consequential damages related to time and costs spent by the Claimant to follow up on the reimbursement(s).

Your Claim Form has been submitted successfully.

Please print this page for your records.

Your Claim Details

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
Billing Provider
Street Address
Street Address 2
City
State
Zip Code
Phone Number
Email Address
Signature
Date

If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at info@HealthProviderSettlement.com

Click here to edit your Claim.