TIMOTHY RAVE v. INFINITY HEALTHCARE PHYSICIANS, S.C.

Case No. 19CV3073 in the State of Wisconsin Circuit Court for Milwaukee County

Submit Claim

GENERAL INSTRUCTIONS

To make a claim under the Settlement, you must complete this form the form online and submit or mail the paper form to the address below. Your Claim Form must be received by the Settlement Administrator by 11:59 p.m. on April 26, 2024. The information will not be disclosed to anyone other than the Court, the Settlement Administrator, and the Parties in this case, and will be used only for purposes of administering this Settlement (such as to audit and review a claim for completeness, truth, and accuracy).

You can submit a Claim for a Benefit under this Settlement if, from April 18, 2013 through present, (i) you paid, directly or indirectly, a basic, retrieval, processing and/or certification fee charged by Infinity Healthcare Physicians, S.C.. Settlement Class Members who submit Verified Claims will be reimbursed four times the total amount of the basic, retrieval, processing and/or certification fees the class member paid.

Settlement Class Members who seek payment from the Settlement must file online or complete and return to the Settlement Administrator at Rave v Infinity Healthcare, PO BOX 23489, Jacksonville, FL 32241 and must be RECEIVED NO LATER THAN APRIL 26, 2024, at 11:59 p.m., Eastern Time.

Before you complete and submit this Claim Form, you should read and be familiar with the Class Notice attached hereto. Defined terms (with initial capitals) used in this Claim Form have the same meaning as set forth in the Settlement Agreement. By submitting this Claim Form, you acknowledge that you have read and understand the Class Notice, and you agree to the Release(s) included as a material term of the Settlement Agreement.

If you fail to timely submit a Claim Form, you may be precluded from any recovery from the Settlement Fund. If you are a member of the Settlement Class and you do not timely and validly seek to Opt-Out from the Settlement Class, you will be bound by any judgment entered by the Court approving the Settlement regardless of whether you submit a Claim Form. You must submit a separate Claim Form for each invoice you received which charged basic, retrieval, processing and/or certification fees.