Submit Claim | AllianceMed Settlement

SETTLEMENT CLAIM FORM

Your mailed claim form must be postmarked on or before October 4, 2020.

Your Information

First Name *

Last Name *

Business Name (if any)

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Fax Number in June 2018 *

Email Address *

* Required Fields

Certification

Under 28 U.S.C. § 1746, I declare under penalty of perjury that: By submitting this claim form, I certify that the information I have provided herein is true and correct to the best of my personal knowledge and belief. I also certify that I received one or more unsolicited telephone facsimile messages of material advertising the commercial availability or quality of any property, goods, or services by or on behalf of AllianceMed, LLC, in June 2018. I understand that under the Settlement Agreement I am forever releasing and waiving any right to seek compensation or make any claim regarding unsolicited facsimile advertisements sent to me by or on behalf of AllianceMed, LLC, in June 2018.

Signature *

Date

Retina Associates Medical Group, Inc. v. AllianceMed, LLC

Case No. 8:18-cv-01670-JVS-KES

United States District Court Central District of California Southern Division

SETTLEMENT CLAIM FORM

Your Claim Form has been submitted successfully.

Submitted Claim ID:
Confirmation Code:
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CLAIM INFORMATION
First Name
Last Name
Business Name
Street Address
City
State
Zip Code
Phone Number
Fax Number
Email Address