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Hilliard Law
Opioid OBO Heirship Survey
Section 1.B: If you are filing a PI Claim due to another’s death from use of opioids, or you are completing this form as the representative of an individual with a claim due to another’s death from use of opioids, please fill out the information below.
Hidden
Case Number
Hidden
Case Type
First Name
Last Name
Name of Deceased Person Who Used Opioids:
Address at Time of Death of Deceased Person Who Used Opioids: (street address, city, state, zip)
Date of Birth of Deceased Person Who Used Opioids:
MM slash DD slash YYYY
Date of Death:
MM slash DD slash YYYY
Cause of Death:
Full Social Security Number (or Taxpayer ID) of Person Who Used Opioids:
Name of Claimant Filing Claim on behalf of the Person Who Used Opioids:
Claimant's Address: (street address, city, state, zip)
Claimant's Relationship to Person Who Used Opioids:
Select
Parent
Sibling
Child
Spouse
Other
Representative Name (if applicable):
Legal Authority for Representative (if applicable):
Select
POA
Legal Guardian
Conservator
PRESCRIBED MEDICATION – Identify any of the following Purdue-brand opioids that the person whose opioid use is the subject of your Non-NAS PI Claim was prescribed. Include evidence of the prescriptions when submitting this Claim Form. (A claim may qualify without prescription if the person who used opioids was a minor at the time the use began.)
OxyContin
MSContin
Dilaudid
Butrans
Hysingla
DHC Plus
MSIR
OxyFast
Oxy IR
Palladone
Ryzolt
Rhodes Generic (name)
SECTION 4.B: Identify any of the following Medication Assistance Treatment (MAT) drugs prescribed to the person whose opioid use is the subject of your Non-NAS PI Claim. Include evidence of the prescriptions when submitting this Claim Form.(If you selected Easy Payment, SKIP this Section.)
Buprenorphine
Butrans
Methadone
Suboxone
Zubsoly
Naltrexone
SECTION 4.C: Identify any of the following medications provided to the person whose opioid use is the subject of your Non-NAS PI Claim during or after an opioid overdose. Include evidence of the prescriptions or administration when submitting this Claim Form. (If you selected Easy Payment, SKIP this Section.)
Narcan
Evzio
Naloxone
INJURIES SUFFERED BY THE DECEASED – INJURIES SUFFERED BY THE PERSON WHO USED OPIOIDS – SECTION 5.A: Please mark all that are applicable to your claim.
ADDICTION
Date Addiction began:
MM slash DD slash YYYY
Opioid that started the addiction:
Diagnosis and Date of Opioid Use Disorder:
WITHDRAWALS
Date(s) withdrawal(s) occurred:
OVERDOSE
Date(s) overdose(s) occurred:
JAIL
Date(s) jail sentence(s) began/ended:
The charge(s):
REHAB
Dates of inpatient or outpatient rehabilitation
MEDICAL PROVIDER INFORMATION – SECTION 7.A: In this section, please identify information for the medical providers (prescribing doctors and pharmacies) who prescribed opioids to the person whose opioid use is the subject of your Non-NAS PI Claim:
Name of Prescriber/Pharmacy and Information
Medical Liens
SECTION 8.A: Did any insurance company pay for medical treatment for the opioid-related injuries that gave rise to your Non-NAS PI Claim?
Select
Yes
No
Name of person who is signing this form:
Phone number of person who is signing this form:
E-Mail of person who is signing this form:
Authorization to Disclose Health Information
Claimant Name
Date of Birth
MM slash DD slash YYYY
SSN:
Patient or Legal Representative / Date
Relationship to Plaintiff (if signed by Legal Representative)
HEIRSHIP DECLARATION / SWORN DECLARATION ( SIGNATORY IS EXECUTOR UNDER DECEDENT’S LAST WILL AND TESTAMENT) – I. DECEDENT (DECEASED) INFORMATION
Name:
Full Social Security Number:
Decedent's Date of Death
MM slash DD slash YYYY
Residence/Legal Domicile Address at Time of Death (street address, city, state, zip)
II. PI CLAIMANT INFORMATION
Your Name:
Your Full Social Security Number:
Your Address (street address, city, state, zip)
Your Relationship to Decedent
Basis of Your Authority to Act for the Decedent
List here and attach copies of all document(s) evidencing the basis for your authority (for example, Last will and Testament)
Attach copies of all document(s) evidencing the basis for your authority (for example, Last will and Testament)
Drop files here or
Select files
Max. file size: 32 MB.
III. HEIRS AND BENEFICIARIES OF DECEDENT
Use the space below to identify the name and address of all persons who may have a legal right to share in any settlement payment on behalf of the claim of the Decedent. Also, state if and how you notified these persons of the settlement, or the reason they cannot be notified.
Name and Information: (street address, city, state, zip)
List here and attach copies of all document(s) evidencing the basis for your authority (for example, a copy of the interstate statute of the state or domicile of the Deceased Claimant at the time of his or her death.
Attach copies of all document(s) evidencing the basis for your authority (for example, a copy of the interstate statute of the state or domicile of the Deceased Claimant at the time of his or her death.
Drop files here or
Select files
Max. file size: 32 MB.
