Submit Claim | Surescripts Antitrust Litigation

Claim Form

If you are a Settlement Class Member and wish to receive a payment, your completed Claim Form must be postmarked on or before January 6, 2022, or submitted electronically to the Claims Administrator on this website on or before January 6, 2022.

Please read the full Notice of Proposed Class Action Settlement (available on this website) carefully before filling out this Claim Form.

To be eligible to receive any money from the Settlements obtained in this class action lawsuit, you must either: (1) Complete your Claim Form online here on or before January 6, 2022; or (2) Complete this Claim Form and mail it, postmarked on or before January 6, 2022 to: Surescripts Antitrust Litigation Claims Administrator, 1650 Arch Street, Suite 2210, Philadelphia, PA 19103.

Failure to submit your completed Claim Form on time by U.S. Mail (properly addressed) or fill out an online Claim Form by the deadline will result in the rejection of your Claim and you will not receive any money from the Settlements.

PART 1: CLAIMANT INFORMATION

First Name *

Middle Initial

Last Name *

Company Name *

Representative

Street Address *

City *

State *

Zip Code *

Email Address

Telephone Number

* Required Fields

PART 2a: PURCHASE INFORMATION

In order to submit this Claim, you or your company must have paid for e-prescriptions routed through the Surescripts network (collectively, “e-prescriptions”) during the period of September 21, 2010 through April 19, 2021.

State the total dollar amount you paid for e-prescriptions routed through the Surescripts network during the Class Period (defined above), in the United States including its territories and the District of Columbia:

E-Prescriptions Amount *

PURCHASE VERIFICATION

For purchases during the Class Period, for e-prescription routing services, purchased within the United States, including its territories and the District of Columbia, routed through the Surescripts network, the year(s) of your purchase(s) and the total dollar amounts:

Service Name	Year	Quantity Purchased	Total Amount Paid

PART 2b: PROOF OF PURCHASE

You must attach Proof(s) of Purchase, such as a receipt or other documentation establishing the year of purchase, Service Purchased, and total amount paid, annually, quarterly, or monthly, for e-prescription routing services claimed. Failure to include Proof of Purchase will result in the Claim being denied. Submission of false or fraudulent Claims may result in the Claim being rejected in its entirety.

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

Please Note: Upload up to 20 documents in a given session. If you need to upload more documentation, submit your claim and then re-enter the claims portal to upload additional documents.

Select File for Upload:

File Description:

File List: No Files Selected

PART 3: SIGNATURE

UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA, I (WE) CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME (US) ON THIS PROOF OF CLAIM AND RELEASE FORM IS TRUE, CORRECT, AND COMPLETE AND THAT THE DATA SUBMITTED IN CONNECTION WITH THIS CLAIM FORM ARE TRUE AND CORRECT.

Signature *

Date

In re Surescripts Antitrust Litigation

Case No. 1:19-cv-06627

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS

Claim Form

If you are a Settlement Class Member and wish to receive a payment, your completed Claim Form must be postmarked on or before January 6, 2022, or submitted electronically to the Claims Administrator on this website on or before January 6, 2022.

Your Claim Form has been submitted successfully.

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
Middle Initial
Last Name
Company Name
Representative
Street Address
City
State
Zip Code
Email Address
Telephone Number
E-Prescription Amount