Claim Form
Contact Information
Please provide contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form.
Payment Election
Please select one of the following payment options, which will be used should you be eligible to receive a settlement payment. Please remember that the Court in charge of this case still has to decide whether to approve the Settlement. Payments will be made once the Court approves the Settlement and after appeals are resolved. Please be patient.
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For PayPal, Venmo, and Zelle payments, if there are any discrepancies, if the account is no longer active, or if the Settlement Administrator deems that payment cannot or should not be made based on the provided information, the Claims Administrator will either contact you for clarification or be authorized to default to a Check payment.
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If domestic or international payment limits apply to your payment, you may receive more than one transmission or you may default to a Check payment.
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Venmo and Zelle payments cannot be made to accounts outside of the United States.
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A valid address is required to process payments. Failure to provide a valid address may result in a delay in check issuance or electronic delivery of funds.
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Payments by Check will be made out to the Name on this Claim Form and mailed to the address on this Claim Form.
Attestation & Signature
By signing below and submitting this Claim Form, I certify that at least once between May 9, 2021, and June 12, 2026, I accessed or utilized a webpage or mobile application operated or associated with Concord Hospital, Inc., Concord Hospital – Laconia, Concord Hospital – Franklin, or Capital Region Healthcare Corporation (the “Concord Web Properties”).
I declare all of the information on this Claim Form is true and correct to the best of my knowledge, information, and belief, and this is the only claim I will submit in connection with this Settlement. I understand the Settlement Administrator may contact me to request further verification of the information provided in this Claim Form.