Claim Portal
NON-NAS PI CLAIM FORM
FOR PURDUE PI TRUST DISTRIBUTION PROCEDURES

 connection: 216.73.216.240

  About this form:


Eligibility and Claim Requirements:

In order to be eligible for a Distribution1 from the Purdue PI Trust (the "PI Trust") for a Non-NAS PI Channeled Claim, a claimant will, among other things, be required to:
  1. Hold such Non-NAS PI Channeled Claim against one or more Debtors;
  2. Provide proof demonstrating usage prior to the September 15, 2019, Petition Date of a qualifying prescribed opioid listed in Exhibit C to the TDP and also provided below (a "Qualifying Opioid"); and
  3. Have timely filed an individual personal injury Proof of Claim for such Non-NAS PI Channeled Claim against one or more Debtors in the Chapter 11 Cases.
Each Holder of a Non-NAS PI Claim seeking an Award from the PI Trust must complete, sign, and submit the following documents so that they are received on or before July 28, 2025, at 11:59 p.m. (Eastern Time) (the "PI Claims Deadline"):
  1. This Non-NAS PI Claim Form;
  2. The applicable HIPAA consent form provided below; and
  3. To the extent the Non-NAS PI Channeled Claim concerns the injuries of a decedent of the Holder of such Claim, the Heirship Declaration, which can be found on the Purdue PI Trust website at https://www.purduepitrust.com or provide valid estate documents authorizing the Holder of the Claim to act on behalf of the decedent's estate.
FAILURE TO SUBMIT THIS NON-NAS PI CLAIM FORM ALONG WITH THE REQUIRED INFORMATION OUTLINED UNDER THE ELIGIBILITY SECTION ABOVE BY JULY 28, 2025, AT 11:59 PM (EASTERN TIME) MAY RESULT IN THE NON-NAS PI CLAIM POTENTIALLY BEING THE SUBJECT OF AN OBJECTION, DISALLOWANCE, OR DENIAL AND NOT RECEIVING ANY DISTRIBUTION.

THE NON-NAS PI TDP AND ANY FORMS REFERENCED IN THIS NON-NAS PI CLAIM FORM CAN BE REVIEWED, DOWNLOADED AND PRINTED ON THE PI TRUST WEBSITE AT https://www.purduepitrust.com2.
1     Capitalized terms used but not defined herein have the meanings ascribed to them in Thirteenth Amended Joint Chapter 11 Plan of Reorganization of Purdue Pharma L.P. and Its Affiliated Debtors [ECF No. 7306] (the "Plan"), the Purdue PI Trust Distribution Procedures for Non-NAS PI Channeled Claims (the "Non-NAS PI TDP"), or the PI Trust Agreement, as applicable.
2     The Non-NAS PI TDP that is currently on the PI Trust Website is substantially complete but may have minor revisions. The Non-NAS PI TDP will be filed with the Bankruptcy Court as part of the Plan Supplement and will be considered by the Bankruptcy Court for approval at the hearing to consider confirmation of the Debtors' Plan on a date to be scheduled.

Instructions for Non-NAS PI Claim Form Submission:

Only one Non-NAS PI Claim Form in addition to the Required Information should be submitted by or on behalf of a Holder of a Non-NAS PI Claim, even if the Claim of such Holder is for multiple injuries to that same Holder (for example, addiction, overdose, jail, etc.).

If the Holder of a Non-NAS PI Claim holds Non-NAS PI Claims for or on behalf of more than one opioid user, then a separate PI Claim Form for each opioid user in addition to the Required Information should be submitted.

Follow the instructions in each section carefully to ensure that this Non-NAS PI Claim Form is submitted correctly. Any section of the Non-NAS PI Claim Form that does not pertain to your Claim should be left blank.

Submitting this Non-NAS PI Claim Form does not guarantee that your Non-NAS PI Claim will be Allowed or that you will receive payment from the PI Trust.

It is the responsibility of the Holder of the Non-NAS PI Claim or its representative to submit this Non-NAS PI Claim Form along with the Required Information (i.e., the HIPAA Form AND the required proof demonstrating usage of a Qualifying Opioid prior to the September 15, 2019 Petition Date as outlined in the Non-NAS PI TDP and below) by the PI Claims Deadline.

If the Non-NAS PI Claim arises from the use of opioids by a deceased Person, then a Death Certificate along with either the Heirship Declaration or valid estate documents (for example, letters testamentary or letters of administration) authorizing the Holder of such Claim to act on behalf of the Decedent's estate must be submitted as well.

This Non-NAS PI Claim Form along with the Required Information can be completed and submitted online at https://www.purduepitrust.com or by sending such completed Forms and Required Information by:
  1. e-mail to purduepitrust@purduepitrust.com,
  2. mail to Purdue PI Trust, P.O. Box 361930, Hoover, Alabama, 35236-1930, or
  3. fax to Purdue PI Trust at 205-716-2364.
Law firms representing more than one PI Claimant, should visit the Law Firm Bulk Submittal tab on the https://www.purduepitrust.com website for additional information regarding submittal of claims for multiple, represented PI Claimants.
PLEASE CONFIRM THE ACCURACY OF ALL INFORMATION CLEARLY AS THE INFORMATION PROVIDED WILL BE USED TO BOTH EVALUATE YOUR CLAIM AND CONTACT YOU.
PART ONE: PERSONAL INFORMATION OF PI CLAIMANT
Please fill out only one of the following sections (Section 1.A or 1.B).
  Section 1.A - Claim for a Living Injured Party
Complete this Section only if you are (i) the Holder of a Non-NAS PI Claim arising from your own use of opioids or (ii) the representative of another living Person who used opioids.
    Full Social Security Number of PI Claimant (or Taxpayer ID or Social Insurance Number)
    Kroll/Prime Clerk Proof of Claim Number(s) in Purdue's Chapter 11 Cases
    Name of Representative (if applicable, i.e., if you are the representative of the opioid user):
(e.g., Power of Attorney, Legal Guardian, Conservator, etc.)

  Section 1.B - Claim for a Deceased Injured Party
Complete this Section only if you are (i) the Holder of a Non-NAS PI Claim arising from the use of opioids by a deceased Person that is your Decedent or (ii) completing this Non-NAS PI Claim Form as such Holder's representative.


Information on Deceased Person Who Used Opioids:
 
    Full Social Security Number of Deceased Person Who Used Opioids (or Taxpayer ID or Social Insurance Number)
    Kroll/Prime Clerk Proof of Claim Number(s) in Purdue's Chapter 11 Cases
 
Information on PI Claimant Submitting This PI Claim Form on Behalf of Deceased Person Who Used Opioids:
*
* - must be the court appointed representative of the deceased Person's estate or the Decedent's legal heir as per the intestate statute of the state or domicile of the Decedent at the time of the Decedent's death, i.e. parent, sibling, child, spouse, etc.


    Name of Representative (if applicable):
  (e.g., Power of Attorney, Legal Guardian, Conservator, etc.)
PART TWO: PRESCRIBED MEDICATIONS
Identify the name brand and/or generic Qualifying Opioid(s) listed below that was prescribed and used by you or the opioid user on whose behalf you are submitting this Non-NAS PI Claim. A list of Qualifying Opioids along with their NDC Labeler and Drug Prefix can be found below.
OxyContin   OxyFast
MS Contin   OxyIR
Dilaudid   Palladone
Hysingla ER   Ryzolt
Butrans   Oxycodone CR/ER
DHC Plus   Morphine Sulfate
MSIR   Hydromorphone

Other Brand Name or Generic - list name(s) below:
Evidence of the prescription(s) demonstrating usage of a Qualifying Opioid prior to the September 15, 2019 Petition Date as outlined below and in the Non-NAS PI TDP MUST be submitted with this Non-NAS PI Claim Form by the PI Claims Deadline, unless you previously submitted such evidence as part of your Proof of Claim in the Debtors' Chapter 11 Cases. Failure to do so will result in the Non-NAS PI Claim being deficient as outlined in the Non-NAS PI TDP and may be the subject of an objection, disallowance, or denial.

TYPES OF EVIDENCE REQUIRED FOR QUALIFYING OPIOIDS


Each Holder of a Non-NAS PI Channeled Claim must provide any of the following documentation listed below in (a) - (e) demonstrating (i) a prescription that sets forth the name of the Holder of the Non-NAS PI Channeled Claim (or its decedent, if applicable), for (ii) an opioid that is a Qualifying Opioid by providing one of the following pieces of evidence with its Non-NAS PI Claim Form so as to be received by the Claims Administrator on or before the PI Claims Deadline, unless such documentation was previously submitted with a Proof of Claim that was timely filed by the Holder of the Non-NAS PI Channeled Claim in the Debtors' Chapter 11 Cases:
  1. Pharmacy prescription records;
  2. Other prescription records, including without limitation:
    1. A visit note in which the prescribing physician listed a prescription for a Qualifying Opioid; or
    2. A signed prescription from a doctor for a prescribed Qualifying Opioid;
  3. A historical reference to a prescribed Qualifying Opioid, including but not limited to:3
    1. A reference in contemporaneous medical records to historical use of a prescribed Qualifying Opioid;
    2. A reference in contemporaneous substance abuse/rehabilitation/mental health records to historical use of a prescribed Qualifying Opioid;
    3. A reference in contemporaneous law enforcement records to historical use of a prescribed Qualifying Opioid; or
    4. A reference in contemporaneous family law or other legal proceeding records to historical use of a prescribed Qualifying Opioid;
  4. A photograph of the prescription bottle or packaging of a Qualified Opioid with the date of the prescription as well as the name of Holder of the Non-NAS PI Channeled Claim (or its Decedent, if applicable), listed as the patient on the prescription bottle or packaging.
  5. Documentation indicating that the Holder of the Non-NAS PI Channeled Claim (of its decedent, if applicable) had at least one prescription for a Qualifying Opioid supplied prior to the September 15, 2019 Petition Date through customer loyalty programs, patient assistance programs ("PAPs") or copay assistance programs provided by the Debtors or one of their successors.

3     The record containing the historical reference must have been created prior to September 15, 2019
PART THREE: TIER DESIGNATION
Please check the tier that applies to the Non-NAS PI Claim. ONLY CHECK ONE. Please refer to the Non-NAS PI TDP for full definitions and qualifying criteria.


Tier 1: You can demonstrate use of a Qualifying Opioid equal to or greater than six (6) months (does not have to be consecutive use) for a period prior to September 15, 2019.

Tier 2: You can demonstrate use of a Qualifying Opioid for less than six (6) months for a period prior to September 15, 2019.


PART FOUR: MEDICAL LIENS
Section 4.A: Did any insurance company pay for medical treatment for the opioid-related personal injuries that gave rise to the Non-NAS PI Claim?
Yes:     

No:     
Section 4.B: In the last twenty (20) years, were you or the opioid user on whose behalf you are submitting this Non-NAS PI Claim Form eligible for coverage by any of the following?

Please answer the question by selecting "Yes" or "No" next to each insurance provider name and provide the requested information as to each. If any insurance carrier who provided coverage is not listed below, please fill in that carrier's information at the bottom of the chart. You may submit the information on additional paper, if needed, in order to provide all of the information requested.


ALL sections must be checked as "Yes" or "No" before the form can be submitted for processing. You will not be able to return to complete or update this information.


Medicare
Was the opioid user eligible for Medicare coverage and/or did Medicare pay for any opioid-related health costs?
 Yes
 No
Medicaid
Did the opioid user have Medicaid coverage and/or did Medicaid pay for any opioid-related health costs?
 Yes
 No
Tricare
Did the opioid user have Tricare coverage and/or did Tricare pay for any opioid-related health costs?
 Yes
 No
VA
Did the opioid user have VA coverage and/or did the VA pay for any opioid-related health costs?
 Yes
 No
Champus
Did the opioid user have Champus coverage and/or did Champus pay for any opioid-related health costs?
 Yes
 No


Private Insurers
 

Private (1)
Did the opioid user have coverage under a Private Insurer and/or did a Private Insurer pay for any opioid-related health costs?
 Yes
 No
Private (2)
Did the opioid user have coverage under a 2nd Private Insurer and/or did a 2nd Private Insurer pay for any opioid-related health costs?
 Yes
 No
Private (3)
Did the opioid user have coverage under a 3rd Private Insurer and/or did a 3rd Private Insurer pay for any opioid-related health costs?
 Yes
 No
Private (4)
Did the opioid user have coverage under a 4th Private Insurer and/or did a 4th Private Insurer pay for any opioid-related health costs?
 Yes
 No
Private (5)
Did the opioid user have coverage under a 5th Private Insurer and/or did a 5th Private Insurer pay for any opioid-related health costs?
 Yes
 No
Private (6)
Did the opioid user have coverage under a 6th Private Insurer and/or did a 6th Private Insurer pay for any opioid-related health costs?
 Yes
 No


Support Documentation


IMPORTANT MESSAGE:
You will NOT be able to return to the portal to upload supporting documentation once you submit your claim; therefore, it is best for you to upload now all available supporting documentation.


You may attach files supporting this Non-NAS PI Claim. Files may include but are not limited to the following:
  • Medical, prescription, etc. records supporting your claim
  • Death Certificate and Estate documents or Heirship Declaration for a deceased opioid user
To attach supporting files for the Non-NAS PI Claim, utilize the tool below:
  1. First, click on "Choose Files" and select the file(s) on your computer that you wish to upload.
  2. Once selected, click on "Attach Files" to attach them to your Claim.

Select File to Upload:


If you do not attach files at this time or have additional files that need to be added later, you will need to provide the documents utilizing one of the following:
  1. email to purduepitrust@purduepitrust.com with "Portal Claim Documents" in the subject line, or
  2. fax to Purdue PI Trust - Portal Claim Documents at 205-716-2364, or
  3. mail to Purdue PI Trust - Portal Claim Documents at P.O. Box 361930, Hoover, AL 35236-1930
Important Reminder: As previously communicated, failure to timely submit the Non-NAS PI Claim Form along with the required information outlined under the Eligibility and Claim Requirements section above for receipt by the PI Trust on or before the PI Claims Deadline of July 28, 2025, may result in the Non-NAS PI Claim being the subject of an objection, disallowance, or denial.
Begin HIPAA Release Form HIPAA RELEASE FORM FOR PURDUE PI TRUST DISTRIBUTION PROCEDURES

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
PART ONE: PERSONAL INFORMATION OF PI CLAIMANT
PART TWO: AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
  1. The following individuals or organizations are authorized to disclose my health records to the parties specified below in section #4:







    (Note: Please list the names of your medical care providers and your health insurance providers that may have records relevant to the resolution of your PI Claim. If you are unsure of the exact legal name of your medical providers and health insurance providers, you can leave this blank, and we will complete it for you with the understanding that you authorize all relevant parties):

  2. The type and amount of information to be used or disclosed is as follows:

    The entire record, including but not limited to: any and all medical records, mental health records, psychological records, psychiatric records, problem lists, medication lists, lists of allergies, immunization records, history and physicals, discharge summaries, laboratory results, x-ray and imaging reports, medical images of any kind, video tapes, photographs, consultation reports, correspondence, itemized invoices and billing information, and information pertaining to Medicaid or Medicare eligibility and all payments made by those agencies, for the following dates:

    Dates of Services - From:      To:

    (Note: List the date range for which the medical providers and insurance companies above may have records relevant to the resolution of your PI Claim. If you are unsure of the exact dates, then leave this blank, and we will complete this section for you with the understanding that you authorize all relevant date ranges).

  3. I understand that the information in my health records may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, as well as treatment for alcohol and drug abuse.

  4. The health information may be disclosed to and used by the following individual and/or organization:

     
    1. Purdue Personal Injury Trust
    2. Edgar C. Gentle, III., of Gentle, Turner & Benson, LLC, as the Trustee and Claims Administrator of the Purdue Personal Injury Trust
    3. Med Lien Solutions

  5. I understand I have the right to revoke this authorization at any time. I understand 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 10 years after the date that I sign it.
  6. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization and forego a recovery under the Purdue Pharma L.P. PI Trust Distribution Procedures for Non-NAS PI Channeled Claims. I understand that no organization may condition treatment, payment, enrollment, or eligibility for benefits on my signing of this authorization. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 1634.524. I understand 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 or HIPAA. If I have questions about disclosure of my health information, I can contact the parties listed above in section #4.
SIGNATURE (CLAIM FORM AND HIPAA RELEASE)
This Non-NAS PI Claim Form must be signed by the Holder of the Non-NAS PI Claim or its Representative or Counsel of Record.





SELECT ONE
IF SIGNING AS THE HOLDER OF THE NON-NAS PI CLAIMANT OR AS HIS/HER REPRESENTATIVE: "I declare under penalty of perjury that the representations made, and the information provided on this Non-NAS PI Claim Form, are true, correct, and complete to the best of my knowledge."
You are providing the Signature as the Holder of the Non-NAS PI Claim (or signature of Representative Completing this Form on Behalf of such Holder).
IF SIGNING AS COUNSEL OF RECORD: "I, as Counsel for the Holder of the Non-NAS PI Claim or its representative PI Claimant, hereby swear under penalty of perjury that the information contained herein is true and accurate to the best of my knowledge made after conducting due diligence, and that this Non-NAS PI Claim Form is being filed with the consent of my client, or or the authority to file on my client's behalf under applicable law, and/or with appropriate power of attorney." You are providing the Signature as Counsel of Record for the Holder of the Non-NAS PI Claim or Its Representative.
CONFIRMATION OF SUBMISSION OF REQUIRED PROOF OF USAGE OF A QUALIFYING PRESCRIBED OPIOID (Please check one):
 I am including with my submission of this Non-NAS PI Claim Form the required evidence of a Qualifying Opioid prescription(s) as required under PART TWO above and as required in the Non-NAS PI TDP;
  OR
 I previously submitted with my Proof of Claim filed in the Debtors' Chapter 11 Cases the required evidence of a Qualifying Opioid prescription(s) as required under PART TWO above and as required in the Non-NAS PI TDP.4
As stated above in PART TWO, evidence of the prescription(s) demonstrating usage of a Qualifying Opioid prior to the September 15, 2019 Petition Date as outlined in the Non-NAS PI TDP must be submitted WITH THIS NON-NAS PI CLAIM FORM by the PI Claims Deadline unless the PI Claimant previously submitted such evidence with its Proof of Claim filed in the Debtors' Chapter 11 Cases. Failure to do so will result in the Non-NAS PI Claim being deficient as outlined in the Non-NAS PI TDP and may be the subject of an objection, disallowance, or denial.

4     The Claims Administrator will verify whether such required evidence is on Kroll's database.