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Get 5000 Explant Payment Claim Form I Nstructions - Tortcomm
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How to fill out the 5000 Explant Payment Claim Form online
This guide provides comprehensive instructions for completing the 5000 Explant Payment Claim Form for individuals who have undergone the removal of Dow Corning breast implants. By following these steps, users can ensure their applications are filled out correctly and submitted on time.
Follow the steps to successfully fill out the claim form.
- Click the ‘Get Form’ button to download the claim form and open it in your preferred document editor.
- Begin filling out the first section with your personal information, including your social security number and date of birth. Ensure that all details are correct to avoid delays in processing.
- Check the box confirming that you are applying for the $5,000 Explant Payment, having had your Dow Corning breast implant(s) removed after December 31, 1990, and on or before ten years from the Effective Date.
- Provide any medical records from your implant removal, such as a hospital bill or surgical report, to support your claim. Attach copies of these records.
- If you require assistance for removal surgery due to financial constraints, check Box 2B to indicate your wish to receive information about the Explant Assistance Program.
- Review all information to ensure accuracy. Sign and date the form at the end, confirming that the information provided is true and complete.
- Submit the completed form and any required medical records by the deadline, which is ten years from the Effective Date.
- After submission, keep a copy of the documents for your records. You may also want to follow up with the Claims Assistance Program if you experience any issues.
- Users can save their changes, download the completed form, print it, or share it through their document management system.
Start your claim process online today to ensure you receive your entitled payment.
The explant assistance program is designed to support individuals undergoing implant removal. This program can provide financial assistance for the surgery and other related costs. For more information on how to access these benefits, refer to the 5000 EXPLANT PAYMENT CLAIM FORM I Nstructions - Tortcomm, which can walk you through the necessary steps.
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