Purdue Pharma PI Claim Questionnaire instructions

This is not the official Claim Form. An official Claim Form will be required in the future in order to enroll in any settlement program. At this time, we are gathering as much information as possible so that we may complete the final Claim Forms in a timely manner.

Please complete this form as completely and thoroughly as you can. When the final Claim Form is approved we will send you a draft to review and sign.

Follow the instructions of each section carefully to ensure that your Questionnaire is submitted correctly. If any section does not pertain to your claim, leave it blank. Submitting this Questionnaire does not guarantee that you will receive payment from the PI Trust. Whether or not you receive payment depends on whether you make the additional required submissions, including medical or pharmacy records showing usage of a qualifying drug, and whether or not your claim meets the eligibility requirements.

If you have not already sent us records showing use of a qualifying drug, or contacted our office, please do so as soon as possible.

Instructions for Submission: You may complete and submit this Questionnaire either here or by mailing to:

PEIFFER WOLF CARR KANE & CONWAY, LLP
1519 ROBERT C. BLAKES SR DR., 1ST FLOOR
NEW ORLEANS, LA 70130