PRETRIAL ORDER NO. 14: Plaintiff Fact Sheet and Service Protocol
JOAN N. ERICKSEN, District Judge.
1. This Order governs the form and service for the Plaintiff Fact Sheet ("PFS") and Authorizations to be completed by all named Plaintiffs in all cases filed in or transferred to this MDL proceeding.
2. Each Plaintiff shall serve Defendants' lead counsel electronically, pursuant to an electronic service procedure to be agreed to by the parties, a completed and signed PFS in PDF format answering the questions posed in Exhibit A, completed and signed medical authorization (using the form attached as Exhibit B), and any responsive documents, in accordance with the schedule ordered by the Court in its Amended Scheduling Order, Pretrial Order No. 13 (and any amendments thereto). Thus, each Plaintiff who has a case pending in this MDL as of the date of this Order shall serve a completed and signed PFS, together with a completed and signed authorization and responsive documents, within 90 days of the date of this Order. For those Plaintiffs who commence their actions after the date of this Order or whose cases are transferred to this MDL proceeding after the date of this Order, a completed and signed PFS, and a completed and signed authorization and responsive documents, shall be served no later than 90 days after the filing of their complaint or short-form complaint, or completed transfer of their case to this MDL proceeding, whichever is later.
3. The information contained in each PFS shall be verified by the responding Plaintiff under oath. Plaintiffs' responses shall be treated as answers to interrogatories under Fed. R. Civ. P. 33 and requests for production of documents under Fed. R. Civ. P. 34. Each PFS shall be signed and dated by the Plaintiff or the proper Plaintiff representative under penalty of perjury; however, they need not be notarized. Each authorization shall be signed and dated by the Plaintiff or the proper Plaintiff representative.
4. Within four (4) weeks of receipt of a PFS, Defendants shall notify the individual Plaintiff's counsel of any core deficiencies, defined as a lack of response to all questions in Section I, Section II, and Section III; Section IV, questions 1, 3, 7, 8, 9, 10; Section V, questions 5, 6, and 7; Section VI, questions 1, 3, 6, 7, 8, and 9; Section VII, questions 1 and 2; Section 8, question 2; Section IX, questions 1, 3, and 4; or lack of signed medical authorizations, via e-mail and U.S. Mail. Co-Lead Counsel shall be copied on the email deficiency notice at an address or addresses designated by Co-Lead Counsel.
5. If a deficiency letter is timely sent, and absent valid explanation or dispute by the Plaintiff, the case shall be excluded from the bellwether pool until the core deficiencies are remedied.
6. The individual Plaintiff's counsel shall respond in writing within three (3) weeks of the date of service of Defendants' deficiency letter by either (1) curing the alleged deficiencies; (2) disputing the alleged deficiencies and setting forth reasons the PFS is not deficient; or (3) explaining why the alleged deficiencies cannot be timely cured.
7. If the dispute cannot be resolved through the meet and confer process, Defendants may put the dispute on the court conference agenda. No case shall be deemed "deficient" before the matter is addressed to the Court.
8. If a case appears on the agenda for two sequential court conferences without resolution, Defendants may make a motion for dismissal for failure to comply with this Court's Pretrial Order as to the allegedly delinquent party. The parties' prior dealings shall be deemed to satisfy the meet and confer requirements of the Local Rules and no additional meet and confer will be required prior to filing. Defendants shall file that motion 14 days in advance of a court conference; plaintiff shall respond 7 days in advance; and the matter shall be heard at the court conference.
9. Deficiencies other than core deficiencies shall be addressed through a meet and confer process between Defendants and individual Plaintiff's counsel. The procedure for bringing unresolved non-core deficiencies to the Court's attention shall be addressed as part of the bellwether selection protocol, but the existence of such non-core deficiencies shall not be grounds for exclusion of the Plaintiff from the overall bellwether pool.
IT IS SO ORDERED.
EXHIBIT A
UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
In re: BAIR HUGGER FORCED AIR MDL No. 15-2666 (JNE/FLN)
WARMING DEVICES PRODUCTS
LIABILITY LITIGATION
PLAINTIFF FACT SHEET
This Document Relates To:
All Actions
Plaintiff: _______________________
(Printed Name)
This Plaintiff Fact Sheet must be completed pursuant to the Pretrial Order by each plaintiff or their personal representative. Section IX must be completed by loss of consortium plaintiffs.
In completing this Fact Sheet, you are under oath and must provide information that is true and correct to the best of your knowledge. Please answer every question, and do not leave any blanks throughout this Fact Sheet. If you cannot recall all of the details requested, please provide as much information as you can. If a question is not applicable to you, please state "Not Applicable" or "N/A." If any information you need to complete this Fact Sheet is in the possession of your attorney or other representative, please consult with that attorney or representative so that you can fully and accurately respond to the questions. If you do not have room in the space provided to complete your answer, please attach as many sheets of paper as necessary to fully answer the questions. You are obligated to supplement your responses if you learn that they are incomplete or incorrect in any material respect. No answer rwequires any waiver of privilege.
As used herein, the term "communication" and/or "correspondence" shall mean and refer to any oral, written or electronic transmission of information, including, without limitation, meetings, discussions, conversations, telephone calls, memoranda, letters, e-mails, text messages, conferences, or seminars or any other exchange of information.
As used herein, the term "identify" or "identity" with respect to persons, means to give, to the extent known, the person's full name, their present or last known addresses and phone numbers.
As used herein, the term "person" means natural person, as well as corporate and/or governmental entity.
As used herein, "your attorney" refers to the attorneys that represent you individually in this lawsuit.
As used herein, the terms "Relating to," "relate to," "referring to," "refer to," "reflecting," "reflect," "concerning," or "concern" shall mean evidencing, regarding, concerning, discussing, embodying, describing, summarizing, containing, constituting, showing, mentioning, reflecting, pertaining to, dealing with, relating to, referring to in any way or manner, or in any way logically or factually, connecting with the matter described in that paragraph of these demands, including documents attached to or used in the preparation of or concerning the preparation of the documents.
NOTE TO PEOPLE IN A REPRESENTATIVE CAPACITY
If you are completing this form in a representative capacity, only the information in Section I asks for information about you, individually. Throughout the rest of the Plaintiff Fact Sheet, the questions seek information about the person who you claim was injured, or on whose behalf you bring this lawsuit. Other than in Section I, when a question asks for information about "you" or the "plaintiff," please provide information about the person you claim was injured or on whose behalf you have brought this lawsuit.
I. CASE INFORMATION
1. Name of person completing this form: ____________________________________________________
2. State the following for the civil action which you filed:
a. Current case caption: ________________________________________________________________
b. Current case number: _________________________________________________________________
3. State the name, address, telephone and facsimile numbers, and e-mail address of the principal attorney representing you:
a. Name: _________________________________________________________________________________
b. Firm: _________________________________________________________________________________
c. Address: ______________________________________________________________________________
d. Telephone: _________________________________ Fax: _____________________________________
e. E-mail: _______________________________________________________________________________
4. If you are completing this questionnaire in a representative capacity (e.g., on behalf of an estate, or incapacitated or deceased person), please state the following information about yourself:
a. Name: ________________________________________________________________________________
b. Any other names (e.g., maiden name or alias) you have used or by which you have been known and the dates you used those names: __________________________________ ______________________________________________________________________________________
c. Your Address: ________________________________________________________________________
d. Individual or estate you are representing, and in what capacity you are representing the individual or estate: ______________________________________________________________________________________
e. If you were appointed as a representative by a court, state the court: ______________________________________________________________________________________
f. Date of Appointment: _________________________________________________________________
g. State your relationship with the represented person claimed to be injured: ______________________________________________________________________________________
h. If you represent a decedent's estate, state the date and the address of the place of death: ______________________________________________________________________________________
II. PERSONAL INFORMATION (re Person claiming injuries)
1. State the following regarding your personal information:
a. Full Name: ___________________________________________________________________________
b. Any other names (e.g., maiden name or alias) you have used or by which you have been known and the dates when you used those names: _____________________________ ______________________________________________________________________________________
c. Social Security Number: ______________________________________________________________
d. Address: _____________________________________________________________________________
e. State how long you have lived at your present address: ______________________________
f. Identify all persons who lived with you at the time of the events alleged in the Complaint, and their relationship to you: ___________________________________________ ______________________________________________________________________________________
2. Driver's license number and state issuing license: ______________________________________
3. Date and place of birth: ________________________________________________________________
4. Sex: Male: _____ Female: ______
5. If you have Medicare. please state your HICN number (if known): ________________
6. Identify each address at which you have resided during the last ten (10) years, and list the approximate years when you started and stopped living at each one:
Address Dates of Residence
____________________________________________________________________________________________
____________________________________________________________________________________________
7. Are you currently, or have you ever been, married? Yes ___ No ____
If "yes," for each spouse, please state the following:
Name and Address (if different Spouse's Date Date Marriage How Marriage
from yours) of Spouse of Birth Began/Ended Ended
____________________________________________________________________________________________
____________________________________________________________________________________________
8. For each of your children, please state their name and year of birth: ___________________ _________________________________________________________________________________________
9. Identify the following information for each school, college, university, vocational school. or other educational institution you have attended beginning with high school:
Name of School City and State Dates of Degree Major or
attendance Awarded Primary Field
____________________________________________________________________________________________
____________________________________________________________________________________________
10. For your cunent employer (if you are not currently employed, your last employer) and each employer for the last ten (10) years, state the following to the extent you can recall:
Name and Address of Approx. Occupation/Job Reason for Leaving
Employer Dates of Title
Employment
____________________________________________________________________________________________
____________________________________________________________________________________________
11. Have you ever served in any branch of the military?
Yes ____ No _____
Branch(es) and date(s) of service ________________________________________________________________________________________
If yes, were you ever discharged for any reason relating to your medical or physical condition?
Yes ____ No _____
If yes, state what that condition was:
12. Have you ever been rejected from military service for any reason relating to your medical or physical condition?
Yes ____ No _____
If yes, state what the condition was: __________________________________________________
13. Have you been convicted of a felony or a crime involving a dishonest act or false statement in the last ten (10) years?
_____Yes _____ No
If "yes," state the type and nature of the underlying conduct or event: ________________________________________________________________________________________
Court/State entering conviction: _______________________________________________________
Date of conviction: ____________________________________________________________________
14. Do you recall ever visiting a website, blog, etc., regarding the use of patient warming systems during surgery, or any risks or benefits to patient warming in general or by device type? If so, identify the website, blog, etc., you visited and the location of any copy of the information you reviewed if it still exists: ________________________________________________________________________________________
15. Do you recall ever posting or writing anywhere on the internet in a public forum about Defendants, any patient warming system or device, or the injuries you allege were caused by Defendants' product, including but not limited to, posting on a personal website, blog, Facebook account, Linked In account, or other social media?
_____Yes _____ No
If "yes," then identify the web address or name and type of social media, and approximate dates during which you made such posts:
16. Do you have any drawings, journals, slides, diaries, notes, letters, or emails which refer to your health or well being relating to your surgery, alleged injury, and your life after your alleged injury? ________________________________________________________________________________________
III. SURGERY INFORMATION
To the extent responsive information to the questions below is available in medical records in your possession or in the possession of your attorneys, please produce such records.
1. Do you have information that a Bair Hugger™ Patient Warming System ("Bair Hugger system") was used during the surgery allegedly connected to the infection at issue?
_____Yes _____ No
If "yes," please describe that information? ____________________________________________ ________________________________________________________________________________________
When did you first discover this information? __________________________________________
How did you learn this? ________________________________________________________________
Provide the Serial or Model Number of the device used: _________________________________
Where is this product now? _____________________________________________________________
2. Other than based upon information from a consulting expert, do you have information as to whether the operating room (where the surgery at which you claim you were injured was performed) utilized a laminar air flow system at the time of your surgery?
_____ Yes, it did. _____ No, it did not. _____ Do not know.
What is the source of your knowledge? ___________________________________________________
When did you learn this? ________________________________________________________________
Other than based upon information from a consulting expert, identify any documents or records that contain information about the laminar air flow system used in the operating room at the time of your surgery: _______________________________________________________ _________________________________________________________________________________________
3. State the following information related to the surgery or surgeries at which you claim you were injured by a Bair Hugger system (answer separately for each surgery at issue):
Date of surgery:_________________________________________________________________________
Location of surgery (hospital or facility name and full address): _______________________ _________________________________________________________________________________________
Identify the physician performing the surgery: __________________________________________ _________________________________________________________________________________________
Type of surgery: ________________________________________________________________________
Reason for surgery: _____________________________________________________________________
Your height and weight at the time of surgery: __________________________________________
List all medical conditions or diagnoses (for example, high blood pressure or diabetes) that you had at the time you went into surgery: _________________________________________ _________________________________________________________________________________________
Identify any infections you had, if any, during the 6 months before you had surgery: ___ _________________________________________________________________________________________
Identify all persons with whom you had discussions about the risks of surgery, and describe the risks discussed: ___________________________________________________________ _________________________________________________________________________________________
Identify the type of microbe, bacterium, virus, or organism, you allege caused the infection that is the subject of this lawsuit (if known) and the basis for your knowledge if not subject to privilege: _______________________________________________________________ _________________________________________________________________________________________
4. Has anyone, excluding any retained medical or scientific expert or your attorneys, expressed the opinion or otherwise told you that the Bair Hugger system caused the infection or injury that is the basis for this lawsuit?
Yes _____ No ____
If yes, identify the person who told you and their relationship to you: ________________________________________________________________________________________
What were you told? ____________________________________________________________________ ________________________________________________________________________________________
5. Are you aware of any non-privileged tests or inspections that have been conducted of the Bair Hugger system allegedly used at your surgery, or of any other Bair Hugger device?
_____Yes _____ No
If "yes," state the following:
Date(s) of testing:______________________________________________________________________
Model/Serial No. of unit(s):_____________________________________________________________
Name and address of person or entity that conducted testing: ____________________________
_________________________________________________________________________________________
Description of tests conducted: _________________________________________________________
_________________________________________________________________________________________
Results of testing: _____________________________________________________________________
_________________________________________________________________________________________
IV. GENERAL MEDICAL INFORMATION
1. Identify the following vital statistics:
Current (last) height: __________
Current (last) weight: __________
2. Identify the name and address of your current (last) family and/or primary care physician: _________________________________________________________________________________________
3. Identify all healthcare providers with whom you have consulted or treated begiiming seven (7) years before the surgery at which you claim you were injured by a Bair Hugger system through the present, and for each provider, state the following information:
Doctor or Specialty Address Approx. Reasons for
Healthcare Dates/Years Seeing this
Provider's Name of Visits Provider
____________________________________________________________________________________________
____________________________________________________________________________________________
4. For each hospital. clinic, surgery center, healthcare facility. physical therapy or rehabilitation center where you have received medical treatment (in-patient, out-patient, urgent care or emergency room) from the time seven (7) years before the surgery at which you claim you were injured by a Bair Hugger system to the present, state the following information:
Name Address and Admission Reason for Admission
Telephone Number Date(s)
____________________________________________________________________________________________
____________________________________________________________________________________________
5. List all of the medications (prescription and over the counter) you currently take.
Medication Dose/Frequency Physician Purpose
of Use Ordering
____________________________________________________________________________________________
____________________________________________________________________________________________
6. For each prescription medication you have taken at least once a month over the course of four months or more at any time during the last seven (7) years prior to the surgery, other than the ones above. identify the following information:
Name of Prescription Who Prescribed the Understanding of Dates/years
Medication Medication Reason for Taking taken
____________________________________________________________________________________________
____________________________________________________________________________________________
7. Identify the following for each pharmacy, drugstore, or other facility or supplier (including, but not limited to, mail order pharmacies) that has dispensed medication to you in the past five (5) years:
Name of Pharmacy Address and Telephone Approx. Dates/Years You
Number of Pharmacy Used Pharmacy
____________________________________________________________________________________________
____________________________________________________________________________________________
8. Identify all dental procedures you had beginning 6 months prior to and continuing through 6 months after the surgery during which you claim you were injured by the Bair Hugger system. For each procedure, provide the following information:
Dentist or Address Date of Type of Procedure
Healthcare Procedure
Provider's Name
____________________________________________________________________________________________
____________________________________________________________________________________________
9. Have you ever used tobacco in any form from the time five (5) years before the surgery at which you claim you were injured by the Bair Hugger system to present?
____Yes _____No
If "yes," check the answer and state the following:
Type(s) of tobacco used: ________________________________________________________
Date on which you began using tobacco: __________________________________________
Date on which you ceased using tobacco (if current user, state N/A): ____________
Amount of tobacco used: ________ per day for _______ years.
Other description of tobacco use: _______________________________________________
10. For the time period starting one (1) year before the surgery at which you claim you were injured by the Bair Hugger system to the present, have you been treated as an in-patient or out-patient for drug or alcohol abuse or addiction?
______ Yes _____ No
If "yes," please provide the name of the facility and approximate dates of treatment ________________________________________________________________________________________
V. INSURANCE AND OTHER CLAIM INFORMATION
1. Identify any person, insurance company (including any Medicare Advantage Organization), or other entity, including Medicare or Medicaid, that provided medical coverage to you (either directly or through a group. including any employer) or paid medical bills on your behalf at any time, beginning five (5) years before your alleged injuries through the present.
Name of Entity Policy Number Name of Policy Approx. Dates of
Holder or Insured Coverage
(if not you)
____________________________________________________________________________________________
____________________________________________________________________________________________
3. Have you ever filed a worker's compensation claim in the last ten (10) years?
____ Yes ____ No
If "yes," please state:
The approximate year of the claim: ______________________________________________________
Your employer: __________________________________________________________________________
Nature of disability: ___________________________________________________________________
4. Have you ever been out of work for more than thirty (30) days in any one or more of the last ten (10) years, for any reasons related to your health excluding maternity leave?
_____ Yes _____ NoB
If "yes," please state:
The approximate date(s) you were out of work: ___________________________________________
The reason(s) you were out of work: _____________________________________________________
5. Have you ever filed social security disability claims (SSI or SSD) or filed a disability claim with a private insurer?
_____Yes _____ No
If "yes," please state:
Approximate year of the claim: __________________________________________________________
Nature of disability: ___________________________________________________________________
Was the claim denied? ____ Yes ____ No
6. Have you ever filed a lawsuit or made a claim, other than the present lawsuit, relating to any bodily injury in the last ten (10) years?
_____Yes _____ No
If "yes," please state:
Approximate date the lawsuit or claim was filed or made: ________________________________
Court/State where the lawsuit was filed: ________________________________________________
Name of the Defendant, if known: ________________________________________________________
Brief description of the claims asserted: _______________________________________________
7. Have you ever filed for bankruptcy subsequent to the date of the surgery in which you claim you were injured by the Bair Hugger system?
_____Yes _____ No
If "yes," state when and in what court, and how the case was resolved. _________________ _________________________________________________________________________________________
VI. CURRENT CLAIM INFORMATION
1. Do you allege that you suffered physical and/or bodily injury related to use of a Bair Hugger system?
_____Yes _____ No
If "yes": describe each bodily injury: _________________________________________________________________________________________
State the approximate date on which you first became aware of the injury(ies) (regardless of whether you associated the injury with the use of a Bair Hugger system):______________ _________________________________________________________________________________________
If you are currently experiencing any symptoms related to an alleged injury that you attribute to use of a Bair Hugger system, describe your symptoms and any treatment you are currently receiving:_________________________________________________________________ _________________________________________________________________________________________
Describe any activities that you can no longer perform, or cannot perform as well, since the time you allege you were injured:___________________________________________________ ________________________________________________________________________________________
Describe any other physical harm or consequences you suffered as a result: ________________________________________________________________________________________
2. Do you allege that use of a Bair Hugger system worsened or aggravated a previously existing injury or condition?
_____Yes _____No
If "yes," describe the previously existing injury or condition, the approximate date of onset of the previously existing injury or condition, and any treatment for and resolution of the injury or condition:_____________________________________________________________ _________________________________________________________________________________________
3. Do you claim damages related to emotional distress or psychological injuries as a result of use of a Bair Hugger system?
____Yes ____No
If "yes," describe the emotional distress or psychological injuries and the approximate date of onset:___________________________________________________________________________ _________________________________________________________________________________________
4. If you are claiming damages related to emotional distress. provide the following information for any psychiatrist, psychologist, or any other mental healthcare professional who has ever treated you, or who you are currently seeing, for any alleged emotional distress or psychological injuries described in the previous question:
Doctor or Specialty Address Reason for Approx.
Healthcare Visit Dates/Years
Provider's Name of Visits
____________________________________________________________________________________________
____________________________________________________________________________________________
5. Have you read or seen any written, televised, or internet-based advertising or labeling material related to a Bair Hugger system other than in consultation with your attorney?
____Yes ____No
If "yes," state which written. televised, or internet-based advertising or labeling materials you read or saw and when you reviewed those materials: __________________________________ _________________________________________________________________________________________
6. In connection with the surgery at which you claim you were injured, were you given any oral or written information or warnings concerning the Bair Hugger system?
____Yes ____No
If "yes," state the following:
When these were given: __________________________________________________________________
A description of the information or warnings: ___________________________________________ _________________________________________________________________________________________
Identify each person or entity from whom you recall receiving the information or warnings listed above: _________________________________________________________________________________________
If you recall, list any questions you asked, and the answers they gave, regarding the information or warnings listed above: _________________________________________________________________________________________
7. Have you or has anyone acting on your behalf (other than your attorney) had any communications with any Arizant or 3M representative regarding your surgery with and/or claim of injuries from use of a Bair Hugger system?
_____Yes _____ No
If "yes," provide the approximate date(s), type (email, phone, letter, etc.), persons involved, if known, and general substance of the communication: ________________________________________________________________________________________
8. Did any representative of Arizant or 3M ever tell you that you got a warranty related to the Bair Hugger™ Patient Warming System or otherwise represent to you the expected performance of the Bair Hugger system?
_____Yes _____ No
If "yes," state the following: provide the approximate date(s), type of communication (email, phone, letter, etc.,), persons involved, if known, and general substance of the representation.
9. Please describe any communications, correspondence, or interactions between You and any representative of Augustine Temperature Management, including but not limited to Dr. Scott Augustine.
VII. ECONOMIC DAMAGES
1. Are you making a claim for loss of past wages or income?
____Yes ____No
If "yes," state the following:
Approximate time you lost from work: ____________________________________________________
Approximate income you claim you lost: __________________________________________________
State your approximate total earned income (including any salary, bonus, and benefits) for each year, beginning three years prior to the injury you allege is related to the use of a Bair Hugger system through the present:
Year Annual gross income
____________________________________________________________________________________________
____________________________________________________________________________________________
2. Are you making a claim for loss of future wages, income, or earning capacity?
____Yes ____No
If "yes," state the following:
Approximate amount of lost future wages or income you are claiming: $ ___________________
Basis for calculation of lost future wages or income: ___________________________________ ____________________________________________________________________________________________
3. Have you paid out-of-pocket medical expenses that are related to any condition that you allege was caused by a defect in a Bair Hugger system?
____Yes ____No
If "yes," state the approximate total amount of out-of-pocket medical expenses incurred: $________________________________________________________________________________________
4. For any expenses claimed above, have they been reimbursed or reduced by any third party?
____Yes ____No
If "yes," identify who reimbursed or reduced these expenses: ____________________________ _________________________________________________________________________________________
5. To your knowledge, has your insurer, or any other entity or person (including the government or a governmental agency or program), paid or incurred any medical expenses related to any condition that you allege was caused by the Bair Hugger system?
____Yes ____No
If "yes," identify the name and approximate dates during which your insurer, or other entity or person, paid or incurred any such medical expenses. ___________________________ _________________________________________________________________________________________
6. Provide a statement of the nature and approximate amount of any other economic damages you claim in this lawsuit: ______________________________________________________ _________________________________________________________________________________________
VIII. PERSONS WITH KNOWLEDGE
1. Identify each person (other than your healthcare providers or attorneys) who possesses important information about the facts of your lawsuit, including your injuries and current medical conditions, to the extent not already listed:
Name Address Relationship Subject Matter
to You of Knowledge
____________________________________________________________________________________________
____________________________________________________________________________________________
2. Has anyone (other than your healthcare providers or attorneys) provided you with a verbal or written statement about the facts or circumstances relating to this lawsuit. including the use of patient warming systems or the conduct or representations of Defendants?
____Yes ____No
If "yes," please identify the person, state when they gave you this statement and summarize its contents: _________________________________________________________________ _________________________________________________________________________________________
IX. LOSS OF CONSORTIUM PLAINTIFFS
1. State the following:
a. Your name: ___________________________________________________________________________
b. Any other names (e.g., maiden name or alias) you have used or by which you have been known and the dates you used those names: __________________________________
c. Your Social Security Number: _________________________________________________________
d. Your address: ________________________________________________________________________
e. State how long you have lived at your present address: _______________________________
2. Sex: Male: ____ Female: ____
3. Identify each address at which you have resided during the last five (5) years. and list when you started and stopped living at each one:
Address Dates of Residence
____________________________________________________________________________________________
____________________________________________________________________________________________
4. Are you currently, or have you ever been, married to the primary plaintiff in this action?
_____Yes _____ No
If "yes," please state when and where you were married, how long you were married, and when and how the marriage ended (if it did): ____________________________________________ _________________________________________________________________________________________
5. Do you have any children with the primary plaintiff?
_____Yes _____ No
If "yes," please identify their names and years of birth:____________________________ _________________________________________________________________________________________
6. Describe separately and in detail each and every loss of care, services, companionship, counsel, advice, assistance, comfort, consortium, or any similar loss you are claiming: _________________________________________________________________________________________
X. DOCUMENTATION
1. Authorizations: Please sign and attach to this Fact Sheet the authorizations for release of records appended hereto.
2. Documents within your possession: if you have any of the following materials in your possession, please attach a copy to this Fact Sheet.
A. All diagnostic tests and test results, including original films or video of ultra sounds, MRIs, x-rays, CT scans, etc., taken during the time from ten (10) years before the surgery at which you allege you were injured by use of a 3M™ Bair Hugger™ Patient Warming System to the present.
B. Copies of all documents from physicians, healthcare providers, or others related to the surgery at which you claim you were injured, any patient warming system, or your recovery from surgery.
C. Any documents that reflect, show or establish the use of a Bair Hugger system during the surgery at which you claim you were injured.
D. All documents related to, concerning, or constituting product use instructions, product warnings, package inserts, warranties, guarantees, or other materials provided to you that relate to the Bair Hugger system.
E. All non-privileged statements obtained from or given by any person having knowledge of facts relevant to your specific case.
F. All documents relating to the surgery at which you claim you were injured, including, but not limited to medical records, medical bills, prescriptions, diaries, notes, rehabilitation instructions, etc., whether made by you or any other person or entity.
G. All documents regarding the health risks or hazards associated with or possibly arising from surgery, which you received or generated in connection with or at any time before the surgery at which you claim you were injured.
H. All documents in your possession that you believe were provided to you by any Defendant (unless they first were given to you by your attorney), related to the claims in your case.
I. All documents and things in your possession that relate to any Defendant and were in your possession before the surgery at which you claim you were injured, related to the claims in your case.
J. If you claim to have suffered a loss of earnings, or lost earnings capacity, your federal tax returns and W-2s for each year, beginning three years prior to the injury you allege is related to the use of a Bair Hugger system through the present.
K. If you claim any loss from medical expenses, copies of all bills from any physician, hospital, pharmacy, or other healthcare provider.
L. Decedent's death certificate (if applicable).
VERIFICATION
Pursuant to 28 U.S.C. § 1746, I declare under the penalty of perjury that all of the information provided in this Fact Sheet is true and correct to the best of my knowledge.
_______________________________
Print Name
_______________________________
Signature
_______________________________
Date
_______________________________
Print Name
(Loss of Consortium Plaintiff)
_______________________________
Signature
_______________________________
Date
EXHIBIT B
LIMITED AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
(Pursuant to the Health Insurance Portability and Accountability Act "HIPAA" of 4/14/03)
TO:
Patient Name:
DOB:
SSN:
I, ____________________________________, hereby authorize you to release and furnish to: Faegre Baker Daniels and/or its designee copies of the following information:
* All medical records, including inpatient, outpatient, and emergency room treatment, all clinical charts, reports, documents, correspondence, test results, statements, questionnaires/histories, office and doctors' handwritten notes, and records received by other physicians, dated from ___________________ (seven years prior to the date of the subject surgery) to the present.
* All autopsy, laboratory, histology, cytology, pathology, radiology, CT Scan, MRI, echocardiogram and cardiac catheterization reports, dated from ___________________ (seven years prior to the date of the subject surgery) to the present.
* All radiology films, mammograms, myelograms, CT scans, photographs, bone scans, pathology/cytology/histology/autopsy/immunohistochemistry specimens, cardiac catheterization videos/CDs/films/reels, and echocardiogram videos, dated from ___________________ (seven years prior to the date of the subject surgery) to the present.
* All pharmacy/prescription records, including NDC numbers and drug information handouts/monographs, dated from ___________________ (seven years prior to the date of the subject surgery) to the present.
* All billing records including all statements, itemized bills, and insurance records, dated from ___________________ (seven years prior to the date of the subject surgery) to the present.
1. To my medical provider: this authorization is being forwarded by, or on behalf of, attorneys for the defendant for the purpose of litigation. You are not authorized to discuss any aspect of the above-named person's medical history, care, treatment, diagnosis, prognosis, information revealed by or in the medical records, or any other matter bearing on his or her medical or physical condition, unless you receive an additional authorization permitting such discussion. Subject to all applicable legal objections, this restriction does not apply to discussing my medical history, care, treatment, diagnosis, prognosis, information revealed by or in the medical records, or any other matter bearing on my medical or physical condition at a deposition or trial.
2. I understand that the information in my health record may include information relating to information about behavioral or mental health services and treatment for alcohol and drug abuse.
3. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire in one year.
4. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed as provided in C.F.R. 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the releaser indicate above.
5. A notarized signature is not required. C.F.R. 164.508. A copy of this authorization may be used in place of an original.
PrintName: ____________________________________________ (plaintiff/representative)
Signature: ____________________________________________ Date:_____________________
