Please complete and sign these documents, and submit to Class Counsel at Keller Rohrback, L.L.P., Attn: Dan Mensher, 1201 Third Avenue, Suite 3200, Seattle, WA 98101, only if you indicated in Part V of your Claim Form that you would do so for purposes of compliance with the Medicare Secondary Payer Act, 42 U.S.C. 1395y(b).

Medical Release

Proof of Representation