HiddenHidden Claimant ID* HiddenHidden Last Name* Claim Submission Form Goidel et al. v Aetna Life Insurance Company U.S. District Court, Southern District of New YorkCase No. 1:21-cv-07619(VSB)CATEGORY CLASS C MEMBERS MUST COMPLETE & RETURN THIS FORM SO IT IS RECEIVED BY BAR DATE TO BE ELIGIBLE FOR AN APPROXIMATELY $10,000 PAYMENT PLEASE READ THIS CLAIM SUBMISSION FORM AND THE ENCLOSED SETTLEMENT NOTICE CAREFULLYELIGIBILITY If you sought or could have sought coverage for one or more cycles of artificial insemination (intracervical insemination (“ICI”) or intrauterine insemination (“IUI)) (described below in Step 2) received between September 1, 2017, and June 1, 2024, you were in an Eligible LGBTQ+ Relationship as described in the Settlement Notice at the time, you have not requested exclusion from this settlement, and you complete and timely submit this form and the required Attestation Form, you may be entitled to an approximate $10,000 payment. Submission of this form is required if you’ve been identified as a Category C Class Member. GENERAL CLAIM SUBMISSION FORM INFORMATION Failure to comply with the instructions for completing a claim described on the next page may result in an ineligible claim. After you submit your claim, if additional information is required to complete your claim, you will be notified by mail and/or email. Any documents submitted as supporting evidence will not be returned. Please retain copies of your documents for your own records. INSTRUCTIONS FOR COMPLETING A CLAIM BEFORE YOU BEGIN COMPLETING THIS FORM, contact the provider or providers you received artificial insemination from between September 1, 2017, and June 1, 2024, and request the following information that will be required to complete this Claim Submission Form. I am participating in a class action settlement related to coverage for the provision of infertility services received between September 1, 2017 and May 31, 2024 and have been asked by my health insurer to provide the following information about the artificial insemination services I received from you during that time: (1)Provider Name (2)Provider Address (3)Provider TIN/PIN (4) National Provider Identifier (NPI)For each service received during the relevant time period, please fill out the following:CPT Code**** Select a Choice ***S4035 (Artificial Insemination; Menotropin)58321 (Artificial Insemination; Intra-Cervical)58322 (Artificial Insemination; Intra-Uterine)Date of Service:* MM slash DD slash YYYY The amount billed to me for this service is: $*The amount I paid for this service is: $*You will also need the CPT Code(s) associated with the artificial insemination(s) you underwent. Descriptions of the applicable CPT Codes used for artificial insemination procedures covered by this settlement are as follows: S4035-Artificial Insemination Menotropin Stimulated intrauterine insemination 58321-Artificial Insemination; Intra-CervicalIn this procedure, the provider inserts prepared live sperm into the cervical canal. 58322-Artificial Insemination; Intra-UterineIn this procedure, the provider inserts prepared live sperm into the uterus through the cervical canal. Cycles of in-vitro insemination (“IVF”) will not qualify you for Class Membership and should not be submitted.In order to be considered for a payment, this Claim Form and the Attestation Form must be fully completed, signed under penalty of perjury, and received by the Settlement Administrator on or before Bar DateSTEP 1: CLASS MEMBER INFORMATIONClass Member Name* First Middle Last Aetna Member Number (W Number):*Social Security Number:* Employer/ Plan Sponsor:* Date of Birth (mm/dd/yyyy):* Class Member Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Class Member Email Address:* Class Member Telephone:*Class Member Telephone Type:**** Select a Choice ***MobileHomeAre you acting on behalf of a deceased or incapacitated Class Member?**** Select a Choice ***YesNoIf you are acting on behalf of a deceased Class Member or a Class Member who does not have the capacity to act on their own behalf, documentation supporting your authority to act on their behalf will be required to validate your claim. To proceed, please complete the representative portion of the claim below and submit documentation substantiating your authority to act on behalf of the above Class Member.COMPLETE THIS PORTION OF STEP 1 ONLY IF YOU ARE ACTING ON BEHALF OF A CLASS MEMBERRepresentative Name First Name M.I. Last Name Representative Address Address City State Zip Code Representative Email Address: Representative Telephone:Telephone Type:*** Select a Choice ***YesNoSTEP 2: ARTIFICIAL INSEMINATION HISTORYPlease provide the information in the following chart for each cycle of artificial insemination that you underwent between September 1, 2017, and June 1, 2024. Supporting evidence for each procedure you include is required and must be submitted with this form to verify your claim. Add additional procedures on a separate piece of paper if necessary. FIRST CYCLE BETWEEN SEPTEMBER 1, 2017 AND JUNE 1, 2024:Date of Service (mm/dd/yyyy):* CPT Code- Check the box(s) that apply (see page 2):* S4035 58321 58322 Provider TIN/PIN:* Provider NPI:* Provider Name:* Provider Address:* Street Address City State Zip Code Provider Phone:*Amount Paid*SECOND CYCLE BETWEEN SEPTEMBER 1, 2017 AND JUNE 1, 2024:Date of Service (mm/dd/yyyy):* CPT Code- Check the box(s) that apply (see page 2):* S4035 58321 58322 Provider TIN/PIN:* Provider NPI:* Provider Name:* Provider Address:* Street Address City State Zip Code Provider Phone:*Amount Paid*THIRD CYCLE BETWEEN SEPTEMBER 1, 2017, AND JUNE 1, 2024:Date of Service (mm/dd/yyyy):* CPT Code- Check the box(s) that apply (see page 2):* S4035 58321 58322 Provider TIN/PIN:* Provider NPI:* Provider Name:* Provider Address:* Street Address City State Zip Code Provider Phone:*Amount Paid*STEP 4: DOCUMENTATION Provide the required supporting evidence to support the procedure(s) described in STEP 3. Examples of acceptable forms for supporting evidence might include a bill from your provider, a medical record or a self-pay agreement. Evidence provided must, at a minimum, confirm (1) that you received a service, (2) what service you received, and (3) that you were billed for that service. Supporting Documentation* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB. STEP 5: CERTIFICATION AND SIGNATUREFull Name* Signature* I certify under penalty of perjury that the information included in this Claim Submission Form and the accompanying supporting evidence are true and correct to the best of my knowledge. ClaimFormNoUnique IDEmailThis field is for validation purposes and should be left unchanged.
