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Lot B_Brown Form - AHP Diet Drug Settlement

Lot B_Brown Form - AHP Diet Drug Settlement

Lot B_Brown Form - AHP Diet Drug

BROWN FORM Diet Drug Settlement With American Home Products Corporation 1 This BROWN FORM is to be used to make a claim to receive an Echocardiogram and interpretive physician visit for compassionate and humanitarian reasons and/or true financial hardship. This BROWN FORM must be filed in conjunction with, or be preceded by a completed PINK or BLUE FORM. Your request will be reviewed based upon the information in this BROWN FORM and your PINK or BLUE FORM. 1. State your name, address, social security number, telephone number and claim number (if known). ___________________________________________________________________________________________________________________ (First Name) (Middle Initial) (Last Name) ___________________________________________________________________________________________________________________ (Street Address) ___________________________________________________________________________________________________________________ (City) (State) (Zip Code) — — (_________)_______________________________________________(_________)_______________________________________________ (Daytime Phone Number & Area Code) (Evening Phone Number & Area Code) ___________________________________________________________________________________________________________________ (Birth Date — Month, Day, Year) (Social Security Number) 18300- ___ ___ ___ ___ ___ ___ ___ (Claim Number) 2. The Settlement Agreement with American Home Products Corporation provides that the Settlement Trustees “may, in their discretion in appropriate cases for compassionate and humanitarian reasons, provide a Transthoracic Echocardiogram and associated interpretive physician visit” to individuals who took the Diet Drugs Pondimin ® (Fenfluramine) 1 and/or Redux (Dexfenfluramine) for 60 days or less and had not been diagnosed with “FDA Positive” 2 levels of valvular regurgitation by September 30, 1999. 3. Do you want to receive such a benefit? ❒ Yes ❒ No 4. The Settlement Agreement with American Home Products Corporation states that the Settlement Trustees may, in their discretion, provide a Transthoracic Echocardiogram and associated interpretive physician visit upon Trial Court Approval of the Settlement in cases of “true financial hardship” for individuals who took the Diet Drugs Pondimin ® and/or Redux and who had not been diagnosed with FDA Positive levels of valvular regurgitation by September 30, 1999. ➮ 1 The chemical name for the drug Pondimin is Fenfluramine. Frequently Fenfluramine was prescribed with Phentermine and the resulting combination was known as “Fen-Phen.” 2 “FDA Positive” refers to mild or greater regurgitation of the aortic heart valve or moderate or greater regurgitation of the mitral heart valve, as further defined in the Settlement Agreement. BROWN FORM - 1

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