Voluntary YAZ Private Lien Resolution Program

Claimant Information

I. General Information

You may have received health insurance benefits from a Private Health Plan Provider.

Please read this document and immediately take the steps noted if you would like to

participate in the Voluntary YAZ Private Lien Resolution Program described below.

The Settlement in which you are participating may require your cooperation concerning

reimbursement claims and obligations related to private healthcare benefits you received. This

packet applies to you if you have received benefits relating to your injury from healthcare

coverage or insurance through a private insurance carrier (collectively referred to in this packet

as “Private Health Plan Provider”), including but not limited to the following:

Health coverage provided through you or your spouse’s employer (applies

to both private company employers and government employers), or

Health coverage that you purchased privately.

As a general matter, private healthcare coverage is provided to you in accordance with a written

policy or plan. In the event that you received benefits through one of the private coverage

groups above, that group MAY have a plan or policy which requires you to (1) notify of them of

your claim or Settlement and/or (2) reimburse them from your Settlement for injury related care

provided; this is known as a “healthcare lien.” Thus you MAY have an obligation to notify and

reimburse your Private Health Plan Provider. If such an obligation exists and the Private Health

Plan Provider is not notified and reimbursed from your Settlement, the Private Health Plan

Provider may seek the following actions if provided in your plan or policy: (i) instituting legal

proceedings against you for benefits provided, (ii) offsetting the amount of benefits provided

against future claims, or (iii) terminating your coverage.

If you have received any correspondence from your Private Health Plan about your claims

against BAYER and/or anticipated Settlement Payment, please notify your attorney

immediately.

II. What Are My Options?

If you have received injury related care from a Private Health Plan Provider you have the

following options:

1) Voluntarily Participate in the YAZ Private Lien Resolution Program (described

below)

a. Participation in the YAZ Private Lien Resolution Program will ensure that if your

Private Health Plan Provider is participating (see Exhibit 1), any obligation on

your part is satisfied. Furthermore, it limits the amount which you may be

obligated to repay and may allow you to receive your settlement sooner. If your

Private Health Plan Provider is not listed on Exhibit 1 you can still participate and

by listing your Private Health Plan Provider on the YAZ Private Lien Resolution

Program Offer and Acceptance form the Administrator will make its best efforts

to contact your Private Health Plan Provider and encourage the Private Health

Plan Provider to participate according to the terms and conditions.

2) Not Participate in the YAZ Private Lien Resolution Program

a. If you choose not to participate in the YAZ Private Lien Resolution Program you

will be responsible for addressing any potential private health plan lien which

may exist. If you fail to address and resolve any such lien you may be held

responsible by your Private Health Plan Provider and it may impact your future

coverage under this plan. Furthermore, according to the terms of the settlement

agreement and release between settling Claimants and Bayer, Bayer will continue

to hold a portion of your settlement funds until any such lien is resolved or 2 years

elapse without Bayer being made aware of a lien interest.

III. What Is The YAZ Private Lien Resolution Program?

The terms of your contract with your Private Health Plan Provider(s) may state that the Provider

is entitled to reimbursement for the cost of your treatment alleged to be caused by a third party.

This contractual reimbursement right would then extend to your YAZ-related medical care

should you receive a Settlement Payment. For example, if your Private Health Plan Provider paid

$10,000 for your medical care related to your use of YAZ and resulting complications, the terms

of your insurance policy contract with your Private Health Plan Provider may require you to

repay that $10,000 from your Settlement Payment. This is known as a “healthcare lien.”

The YAZ Private Lien Resolution Program has been established to resolve certain Private Health

Plan Provider interest in a manner that the Garretson Resolution Group, the Administrator of the

Private Lien Resolution Program, believes is favorable to the affected Claimants. The primary

benefit to participating claimants is that certain Private Health Plan Providers have entered into

an agreement with certain Plaintiffs’ Counsel which obligates the Providers to reduce the amount

of a client’s lien repayment obligation by at least 50%.

The program is entirely voluntary. You are not obligated to participate. However, if you

choose not to participate, you may still be responsible for resolving any lien claimed by

your Private Health Plan Provider, and that Provider may not offer you the 50% reduction

and overall cap (described below) in lien amount that is provided by this program. This

document explains the program’s mechanics should you choose to participate.

Claimants may voluntarily elect to participate in the program according to its terms and

conditions, regardless of whether their Private Health Plan Provider has yet notified them of a

YAZ-related lien. A complete list of the Private Health Plan Providers participating in this

Voluntary YAZ Private Lien Resolution Program is contained in Exhibit 1, attached.

IV. What Are The Terms and Conditions of The YAZ Private Lien Resolution Program?

Eligibility – Exhibit 1 contains a listing of the Private Health Plan Providers who are currently

participating in the Voluntary YAZ Private Lien Resolution Program. If you have received

healthcare benefits from any of the Private Health Plan Providers listed on Exhibit 1, you are

eligible to participate in this Voluntary YAZ Private Lien Resolution Program. Since many

Claimants may not know the proper name of their health care program, if you have any doubt as

to whether your insurance provider is participating in this Program, you may still follow the steps

below and the Lien Resolution Administrator will take appropriate steps to verify whether or not

your Private Healthcare Plan is participating in the Program. If your Private Health Plan

Provider is not listed on Exhibit 1 you can still participate and by listing your Private Health Plan

Provider on the YAZ Private Lien Resolution Program Offer and Acceptance form the

Administrator will make its best efforts to contact your Private Health Plan Provider and

encourage the Private Health Plan Provider to participate according to the terms and conditions.

If a Private Health Plan Provider does not voluntarily agree to participate in the Program then the

Provider is not bound by terms of the Program.

Audit – If you choose to participate and if your Private Health Plan Provider is participating in

the Program, the Garretson Resolution Group will obtain from your Private Health Plan Provider

its documentation regarding the YAZ-related expenditures it made on your behalf (“claimed

expenditures”). Sometimes claimed expenditures might inadvertently include claims for charges

that are not related to your YAZ use or subsequent injuries. These are known as “unrelated

charges” and they will not be included in the total amount of the lien. For example, if a YAZ-

related lien for $10,000 contains $2,000 worth of unrelated charges, the auditing process will

identify those and reduce the lien amount to $8,000 (“Injury-Related Lien Amount”). This

ensures that your repayment obligation does not include any expenditures unrelated to YAZ.

Lien Reductions and Caps - As part of the Voluntary YAZ Private Lien Resolution Program,

the participating Private Health Plan Providers have agreed to reduce automatically all post-audit

Injury-Related Lien Amounts by 50% (“Adjusted Lien Amount”). In addition to automatically

reducing all participating Private Health Plan Provider liens by 50%, the participating Private

Health Plan Providers have also agreed to limit or “cap” a lien at 15% of Gross Settlement

Amount (“Capped Lien Amount”) when only one Private Health Plan Provider has a lien. In the

event that two or more Private Health Plan Providers have a lien against the same claimant the

cap is 17.5% of Gross Settlement Amount and the Private Health Plan Providers will split a pro

rata share of the Capped Lien Amount. A claimant’s repayment obligation under the Program

will be limited to the lesser of the Capped Lien Amount or Adjusted Lien Amount.

Example A: If your Gross Settlement Amount is $20,000 and your Private Health Plan Provider

paid $10,000 for your medical care related to YAZ, the $10,000 lien amount will be reduced by

50% to $5,000 (Adjusted Lien Amount). The Adjusted Lien Amount will then be capped at only

15% of the total Gross Settlement Amount of $20,000, which results in a Capped Lien Amount

of $3,000 (See Scenario A in the chart immediately below).

Example B: If your Gross Settlement Amount is $50,000 and your Private Health Plan Provider

paid $10,000 for your medical care related to YAZ, the $10,000 lien amount will be reduced by

50% to $5,000 (Adjusted Lien Amount). The Adjusted Lien Amount will then be capped at

only 15% of the total Gross Settlement Amount of $50,000, which results in a Capped Lien

Amount of $7,500. Note that in this example the Capped Lien Amount of $7,500 is more than

the Adjusted Lien Amount of $5,000. In this example, the maximum amount you must

reimburse will be the Adjusted Lien Amount of $5,000. (See Scenario B in the chart

immediately below).

Example A Example B

Gross Settlement Amount $20,000 $50,000

Injury-Related Lien Amount $10,000 $10,000

Adjusted Lien Amount (50% reduction) $5,000 $5,000

Capped Lien Amount $3,000 $7,500

Amount You Must Reimburse $3,000 $5,000

These reductions and caps provide a great benefit to Claimants by substantially reducing the

Claimant’s reimbursement obligation. Without these reductions and caps, your Private

Health Plan Provider(s) may be entitled to recover the entire amount of its lien from your

Settlement Payment, even if that results in the Private Health Plan Provider receiving most or

all of your net Settlement Payment. Participation in the Voluntary YAZ Private Lien Resolution

Program eliminates this risk to Claimants whose YAZ-related medical expenses were paid by a

participating Private Health Plan Provider.

In addition to the reductions and caps explained above, a further benefit of the program is a cap

at 20% cap of Gross Settlement Amount of the Private Health Plan Provider lien when a claimant

has also has a Federal Medicare (Parts A, B, C or D), Medicaid, Tricare, VA, etc. In practice, if

a Claimant has a reimbursement obligation to any of the aforementioned governmental insurance

programs that equals or exceeds 20% of Gross Settlement Amount then a Private Health Plan

Provider lien will be reduced to $0.00.

Example A: If your Gross Settlement Amount is $50,000 and Medicare A&B paid $2,500 and

Medicaid paid $2,500 (total government repayment obligation of $5,000) and the Private Health

Plan Provider paid $15,000. Because you must pay $5,000 for government repayment

obligations the Private Health Provider Plan cannot recover more than $5,000 (20% of Gross

Settlement Amount is $10,000 minus $5,000).

Example B: If your Gross Settlement Amount is $50,000 and Medicare A&B paid $2,500 and

Medicaid paid $8,000 (total government repayment obligation of $10,500) and the Private Health

Plan Provider paid $15,000. Because you must pay $10,500 for government repayment

obligations the Private Health Provider Plan recovers $0. (20% of Gross Settlement Amount is

$10,000 and government repayment exceeds this amount).

Example C: If your Gross Settlement Amount is $50,000 and Medicare A&B paid $0.00 and

Medicaid paid $0.00 (total government repayment obligation of $0) and the Private Health Plan

Provider paid $15,000. Because there is no government repayment obligation the total amount

you must reimburse the Private Health Plan Provider is $7,500 (20% of Gross Settlement

Amount not applicable because no government repayment; standard cap of 15% applies-

$7,500).

Example A Example B Example C

Gross Settlement Amount $50,000 $50,000 $50,000

20% Cap Amount $10,000 $10,000 $10,000

Gov’t Insurance Repayment $5,000 $10,500 $0.00

Injury Related Lien Amount $15,000 $15,000 $15,000

Amount You Must Reimburse Your

Private Health Plan Provider

$5,000 $0 $7,500

State Laws – If at the time of your YAZ-related injury, you lived in any of the following states,

GRG will determine whether or not any state Anti-Subrogation Laws or Non-Equity Rules

would apply that might eliminate your obligation to certain Private Health Insurance Providers.

These states with Anti-Subrogation Laws are: Arizona, Connecticut, Kansas, Missouri, New

Jersey, North Carolina, New York and Virginia. These states with Non-Equity Rules are:

Illinois, Louisiana, Maine, Michigan, New Hampshire, Ohio and South Carolina.

Direct Payment – If you participate in this Voluntary YAZ Private Lien Resolution Program,

your final lien obligation will be paid directly to your Private Health Plan Provider(s) out of your

Settlement Payment. The remainder of your settlement monies will then be disbursed to you by

your attorneys (after attorneys’ fees and expenses, and any other liens are deducted). You will

not have to do anything to ensure payment of the final lien obligation amount to your Private

Health Plan Provider(s). Once your lien is resolved, the Garretson Resolution Group will

provide you a statement showing your final Private Health Plan Provider lien obligation amount

and confirming that payment has been made to your Private Health Plan Provider(s).

Accordingly, while the Program is carried out, a portion of your Gross Settlement Amount will

be withheld. One of two scenarios will occur: 1) your final Private Health Plan Provider lien

obligation amount plus the $200 administrative fee described below will be held back; or 2) if

the Garretson Resolution Group has not yet finalized your lien obligation, the applicable Capped

Lien Amount described above, plus the $200 administrative fee described below, will be held

back while the Garretson Resolution Group works to finalize the precise amount of your lien

obligation. Once the final amount of your lien is known, the Garretson Resolution Group will

promptly notify you and ensure that you are refunded any monies in excess of that amount was

temporarily held back.

Administrative Expense – The minimum Administrative Expense for a Claimant to participate

in this Voluntary YAZ Private Lien Resolution Program is $75.00 that will be paid to the

Garretson Resolution Group. If a Claimant is determined to have a lien and it is resolved

through the Private Lien Resolution Program, then an additional fee of $125.00 will be due from

the Claimant. However, if a lien is not found through the Program, then no additional funds will

be due from the Claimant. Your Private Health Plan Provider(s) will also pay a $200.00 fee if

you participate in this program and a lien is resolved.

Multiple Private Health Plan Providers - In the event that you received YAZ-related medical

benefits from multiple participating Private Health Plan Providers, the Lien Reductions and Caps

described above would apply to all Private Health Plan liens. In other words, no more than

17.5% of your gross settlement (20% if the aggregate cap applies) would be subject to Private

Health Plan liens regardless of the number of liens. Also you would pay only a single

administrative fee of $200.00 to participate in the Lien Resolution Program.

Confidentiality – If you elect to participate in this Program, the Garretson Resolution Group

will be required to exchange certain information with the participating Private Health Plan

Provider, including information regarding your claimed YAZ-related injury, certain other

Medical Information, and your Social Security Number. Other than for the purposes described in

this document and the attachments described below, the Garretson Resolution Group will hold

your private information in the strictest confidence.

BAYER Holdback - Under the terms of its Master Settlement Agreement BAYER has the right

to hold back funds it deems appropriate to cover the Claimants' responsibilities to pay lien

claims.

V. What If I Don’t Participate?

As explained above, participation in the Voluntary YAZ Private Lien Resolution Program is

entirely voluntary. You are free to elect to not participate. At the present time, however, the

defendant BAYER is refusing to authorize the release of 30% of settlement funds to

Claimants who do not choose to participate in this Program. BAYER is concerned that it

can ultimately be held liable by the Private Health Plan Providers for Claimants’ repayment

obligations. The Private Health Plan Providers participating in the Program have agreed to

absolve BAYER from any potential liability for the release of settlement funds to Claimants who

choose to participate in the Program. Thus, if you participate in the YAZ Private Lien

Resolution Program, this withheld amount will be used to pay, pursuant to the Program’s terms,

any private liens you may have, with any excess to be released to you. If you do not participate,

according to the terms of the settlement agreement and release between settling Claimants and

Bayer, BAYER will not release any portion of these funds to you until you can provide proof

that you have satisfied any potential Private Health Plan Provider claims against your YAZ-

related Settlement or 2 years elapse without Bayer being made aware of a lien interest.

If you choose not to participate in the Voluntary YAZ Private Lien Resolution Program, your

Private Health Plan Provider may never identify you as the recipient of a YAZ settlement, and

they may never contact you seeking the repayment of any YAZ-related medical expenses.

However, this does not mean that they will forfeit any contractual right of reimbursement they

may have against those who choose not to participate. Further, your Private Health Plan

Provider may identify you through their own efforts and contact you directly to resolve any liens

it may have against your YAZ settlement proceeds, pursuant to the terms of your individual

health insurance policy. You will then be responsible for resolving any such liens through your

own efforts. Importantly, those Participating Private Health Plan Providers have stated that they

will not offer the reductions and caps discussed above that they have agreed to provide under this

Voluntary YAZ Private Lien Resolution Program. This means that if you choose not to

participate, your eventual repayment obligation for your Private Health Plan Provider could

ultimately be larger than it would be if you participated in the voluntary Program.

VI. What Do I Need To Do Next?

If you would like to participate in the Voluntary YAZ Private Lien Resolution Program as

described above, you must sign and return both the attached “Notice of YAZ Private Lien

Resolution Program Offer and Acceptance” and the “Authorization for Use and Disclosure of

Protected Health Information” immediately to the address listed below. It is extremely

important that you FULLY complete the necessary fields on the “YAZ Private Lien

Resolution Program Offer and Acceptance” to include Name, Social Security Number,

Plan Name, Plan ID (also known as Member #), and then sign the bottom. Failure to fully

complete the “YAZ Private Lien Resolution Program Offer and Acceptance” could prevent

your healthcare lien from being resolved through the YAZ Private Lien Resolution

Program.

Garretson Resolution Group, Inc

P.O. Box 12540

Charlotte, NC 28220

Phone: (877) 774-1130

YAZ Exhibit 1: PLRP Participating Plan List

Participating Plan Name: Date Added:

Aetna, Inc.

AEI\BCBS PPO (Meritain Health, subsidiary of Aetna) 11/30/2012

AMERIGROUP

Alliance PPO (UnitedHealth Group, Inc.) 11/30/2012

Allied Benefit Systems (Cigna) 1/16/2013

Altius Health Administration (Coventry) 1/16/2013

American Medical Security (UnitedHealth Group, Inc.) 11/30/2012

AmeriChoice (UnitedHealth Group) 1/16/2013

Anthem (Anthem BCBS/Wellpoint)

Arkansas BCBS

Assurant Health

AvMed, Inc.

BCBS Alaska (part of Premera) 1/16/2013

BCBS Alliance Choice (Anthem) 11/30/2012

BCBS Association (BCBS Federal)

BCBS Arkansas (Health Advantage)

BCBS Blue Advantage HMO (WellPoint/Anthem or BCBS IL) 11/30/2012

BCBS Blue Choice PPO (part of BCBS TX) 1/16/2013

BCBS Colorado

BCBS Connecticut

BCBS Delaware

BCBS Georgia

BCBS Kansas City

BCBS Kentucky

BCBS Florida (Florida Blue) 12/13/2012

BCBS Hawaii

BCBS Illinois

BCBS Indiana

BCBS Lumenos (WellPoint/Anthem) 11/30/2012

BCBS Maine

BCBS Missouri

BCBS Nebraska

BCBS Nevada

BCBS New Hampshire

BCSB New Mexico

BCBS North Carolina

BCBS North Dakota (Noridian)

BCBS of Western NY (HealthNow NY) 11/30/2012

BCBS Ohio

BCSB Oklahoma

Participating Plan Name: Date Added:

BCBS Preferred Care Blue

BCBS Premera 11/30/2012

BCBS Sprint (part of BCBS Illinois) 1/16/2013

BCBS State Health Plan (BCBS NC) 11/30/2012

BCBS Texas (except for its State of Texas plan)

BCBS TRS-Activecare (part of BCBS Texas) 1/16/2013

BCBS UT Select PPO (part of BCBS Texas) 1/16/2013

BCBS Vermont

BCBS Virginia

BCBS Wisconsin

Blue Cross of California

Blue Cross Prudent Buyer (Wellpoint) 1/16/2013

Blue Shield of California

Blue Shield of NE NY (part of HealthNow NY) 1/16/2013

CareFirst, Inc. (Care First Blue Choice)

Cariten (Humana)

Choice Plus (UnitedHealth Group) 1/16/2013

CIGNA HealthCare, Inc.

Concordia Health Plan (Cigna) 1/16/2013

Coventry Health 1/3/2013

EHP Classic (Johns Hopkins Healthcare) 11/30/2012

EmblemHealth, Inc.

Empire BCBS (BCBS Empire New York)

Exxon Mobil Med Plan Aetna POS II (Aetna) 11/30/2012

First Health Coventry Health Care (Coventry) 1/3/2012

Fortis (Assurant Health) 11/30/2012

GEHA 11/30/2012

Great West Healthcare (Cigna)

Group Health Cooperative (Including KPS)

Group Health Inc. (GHI)

Government Employees Health Assoc. (GEHA)

Harvard Pilgrim Health Care, Inc.

Hawaii Medical Service Association

Health Advantage BCBS POS (part of Arkansas BCBS) 1/16/2013

Health America (Coventry) 1/3/2013

Health Assurance (Coventry) 1/3/2013

Health Care Service Corporation

Health Insurance Plan of Greater New York (HIP)

Health Net, Inc.

Healthlink (Wellpoint) 1/16/2013

HealthNow New York, Inc.

Participating Plan Name: Date Added:

HealthPartners, Inc.

Health Plan of Nevada (UnitedHealth Group, Inc.) 11/30/2012

HIP Plan of New York (Emblem) 11/30/2012

HMO Colorado (Wellpoint) 11/30/2012

HMSA/BCBS (BCBS Hawaii) 11/30/2012

Humana, Inc. IBA Health Plan Dual Select (United HealthCare employer group) 11/30/2012

IND Keystone Flexible Choice (Wellpoint) 1/16/2013

John Alden Life Insurance Co.

Johns Hopkins Healthcare

Kanawha (KHS) (Humana) 11/30/2012

Lifewise Health Plan of Washington (Premera) 11/30/2012

MAMSI (UnitedHealth Group) 1/16/2013

Medical Mutual of Ohio (MMOH) 11/30/2012

Meritain Health (Aetna)

One Net PPO (UnitedHealth Group, Inc.) 11/30/2012

Oxford Health Plan

Pacificare (UnitedHealth Group) 1/16/2013

Passport Health Plus 11/30/2012

PersonalCare Insurance (Coventry) 1/3/2013

Preferred Health Systems (Coventry) 1/3/2013

Preferred One (WellCare) 1/16/2013

Premera 11/30/2012

Priority Health

Premera, Inc.

Quality Net Care Care First BC/BS (CareFirst) 11/30/2012

Sagamore Health Network (CIGNA) 11/30/2012

Sierra Choice (now UnitedHealth Group, Inc.) 11/30/2012

Starbridge (Cigna)

Time Insurance Co.

Tufts Associated Health Plans, Inc.

Tulane University (UnitedHealth Group) 1/16/2013

Unicare (WellPoint)

Unison (UnitedHealth Group) 1/16/2013

UnitedHealth Group, Inc.

Union Security Insurance Co.

Verizon

Vytra (HIP and part of Emblem) 11/30/2012

WellCare Health Plans

Wellpoint

YAZ PRIVATE LIEN RESOLUTION PROGRAM

OFFER AND ACCEPTANCE

I have read and understand the document titled “Voluntary YAZ Private Lien Resolution Program, Claimant Information”

which explains the offer of the YAZ Private Lien Resolution Program. Having been fully informed of the offer, I elect to

participate in the YAZ Lien Resolution Program according to the terms and conditions outlined in that document.

A. CLAIMANT INFORMATION

PARTICIPATING CLAIMANT

INFORMATION

INFORMATION OF INDIVIDUAL WHO TOOK YAZ

IF NOT THE SAME AS THE PARICIPATING

CLAIMANT

Last Name Last Name

First Name First Name

SSN___-___-____ Date of Birth SSN___-___-____ Date of Birth

ADDRESS OF THE INDIVIDUAL WHO TOOK YAZ AT THE TIME OF THE INJURY-RELATED MEDICAL TREATMENT

Address

City State Zip Code

Check the appropriate box that applies to you (check only one):

I am an adult claiming YAZ-related injuries and signing for myself.

I am the Parent or Legal Representative of a disabled adult or a minor who claims YAZ-related injuries.

I am the Authorized Representative of a deceased individual who claims YAZ-related injuries.

If checked, please indicate date of death: _________________________

B. PRIVATE HEALTH INSURANCE COVERAGE

Provide the following additional information. Identify each of the healthcare providers or insurers that you believe

may have paid in any way for care related to your YAZ-related injuries since the first date of your YAZ injury through

the date of settlement. Be as specific as possible. If you have a copy of the applicable health insurance card, please

enclose a copy of that card as well.

B.1. Private Health Insurance Plan(s)

Plan

Name

Member/Plan

ID #

Employer

Name

Plan

Name

Member/Plan

ID #

Employer

Name

Plan

Name

Member/Plan

ID #

Employer

Name

Plan

Name

Member/Plan

ID #

Employer

Name

If you have received correspondence from a Private Health Insurance Provider(s) inquiring about your YAZ

settlement, attach copies of the correspondence and return them with this questionnaire.

C. RETURNING THIS FORM

Please return this Form and the “Authorization to Disclose Health Information Form” and any enclosures at your

earliest convenience and submit the materials to:

Garretson Resolution Group

P.O. Box 12540

Charlotte, NC 28220

Signature By:____________________________ Date _____/___/______

Authorization for Use and Disclosure of Protected Health Information

Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (45 C.F.R. §164.508) To: Medicare Advantage Health Plans, Private Health Insurance Commercial Plans, and Recovery Contractors Re: _____________________________________________________ (Name of YAZ Claimant) Date of Birth_______________ Purpose: This document will authorize the following person(s)/entity to represent me for purposes of resolving subrogation and/or reimbursement interests/healthcare liens, if any, in my personal injury claim if any, in my personal injury claim relating to the Yaz settlement to which I am a participant. The entities and persons named below are authorized to request and receive from you any and all information related to this claim, and discuss, negotiate, and ultimately resolve this claim on my behalf. This authorization also applies to review and access to online websites containing my Protected Health Information (defined below), including but not limited to Mymedicare.gov. Information to be Disclosed: Healthcare lien/claim information, including but not limited to diagnosis and other procedural codes, as well as medical records, whether electronic or otherwise, regarding enrollment status, and/or any payments made, or medical care performed or paid for by the healthcare lien/claim holder relating to the injury-related charges for the period beginning with the date of incident (“Protected Health Information”). Person(s)/Entity Authorized to Receive and Use Protected Health Information: The Garretson Resolution Group, its agents, employees, affiliates, subsidiaries, or representatives (“GRG”). Mailing Address: Garretson Resolution Group 2115 Rexford Road, 4th Floor Charlotte, NC 28211 I hereby direct any healthcare lien/claim holder, its contract representative and/or the plan/claims administrator (the “Disclosing Party”) to release my Protected Health Information, described above, to GRG. I understand that GRG may re-disclose this information in its efforts to resolve my healthcare liens/claims. Furthermore, I understand that my Protected Health Information will no longer be protected by Federal privacy regulations. Therefore, I release the Disclosing Party from all liability arising from the disclosure of my Protected Health Information under this Authorization. Right to Revoke: I understand that I am entitled to inspect the terms of this Authorization, and I may request and receive a copy of the same if the Disclosing Party requested this Authorization. I understand that I may inspect or request copies of my Protected Health Information disclosed by this Authorization. I understand that I may revoke this Authorization by notifying the Disclosing Party or authorized entities in writing, knowing that previously disclosed information would not be subject to my revocation request. I understand refusal to authorize disclosure of my Protected Health Information will have no effect on enrollment, coverage, or the amount paid, or to be paid, for the health services I receive. This authorization will expire two (2) years from the date following the resolution of my healthcare lien/claim, and may be signed via electronic signature, facsimile signature, or original signature all of which will be legally binding as if it was the original signature. _______________________________ _________________________________________ __________ Claimant/Injured Party Signature Print Name Date OR _______________________________ _________________________________________ __________ Personal Representative Signature Print Name, and Title (based on authority to act) Date (i.e., guardianship/conservatorship letters of authority, powers of attorney, etc. attached)