*PYEONE*
Teblum v. Physician Compassionate Care LLC
d/b/a DocMJ Settlement Administrator
P.O. Box 43502
Providence, RI 02940-3502
PYE
Settlement Claim Form
FOR CLAIMS
PROCESSING
ONLY
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DOC
LC
REV
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Return this Claim Form to: Teblum v. Physician Compassionate Care LLC d/b/a DocMJ Settlement Administrator,
P.O. Box 43502, Providence, RI 02940-3502. Questions, visit www.PhysicianCompassionateCareTCPAsettlement.com
or call 1-844-917-2017.
DEADLINE: THIS CLAIM FORM MUST BE FULLY COMPLETED, BE SIGNED UNDER OATH, AND MEET
ALL CONDITIONS OF THE SETTLEMENT AGREEMENT. THIS CLAIM FORM CAN BE SUBMITTED
BY U.S. MAIL BUT MUST BE POSTMARKED ON OR BEFORE 8/27/2022. THIS CLAIM FORM CAN BE
SUBMITTED VIA EMAIL AT INFO@PHYSICIANCOMPASSIONATECARETCPASETTLEMENT.COM
OR ONLINE AT WWW.PHYSICIANCOMPASSIONATECARETCPASETTLEMENT.COM BUT MUST BE
SUBMITTED NO LATER THAN 11:59 P.M. EASTERN ON 8/27/2022.
YOU MUST SUBMIT THIS CLAIM FORM TO RECEIVE A SETTLEMENT PAYMENT.
Please note that if you are a Class Member, the Class Member Verication section below requires you to state, under penalty
of perjury, that all information contained therein is true and correct. This Claim Form may be researched and veried by the
Settlement Administrator.
First Name M.I. Last Name
Primary Address
City State ZIP Code
— —
Telephone Number on the Date you Received a Text Message
Email Address
— —
or ll in if same as above
Current Phone Number
(Please provide a phone number where you can be reached if further information is required.)
Claim ID
Teblum v. Physician Compassionate
Care LLC d/b/a DocMJ
UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDA
Case No. 2:19-cv-00403-SPC-MRM
Must Be Postmarked
No Later Than
August 27, 2022
