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UNITED STATE DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF FLORIDA
MIAMI DIVISION

MDL NO.: 1334

IN RE: MANAGED CARE LITIGATION

THIS DOCUMENT RELATES ONLY TO
PROVIDER TRACK CASES

WELLPOINT PHYSICIAN GROUP AND
PHYSICIAN ORGANIZATION SETTLEMENT
COMPLIANCE DISPUTE CLAIM FORM

The undersigned hereby declares that he or she is a Class Member and did not Opt-Out of the Wellpoint Physician, Physician Group and Physician Organization Settlement Agreement.

Check one of the following:

•       I am bringing this Compliance Dispute on my own behalf.
•       I hereby authorize the following Signatory Medical Society to bring
        this Compliance Dispute on my behalf. (Enter name below to indicate signature)

Set forth in detail below, using particularized facts, the specific obligation(s) of Wellpoint to you under Section 7 of the Settlement Agreement which you allege Wellpoint has materially failed to perform. Describe how you have been adversely affected by Anthem/Wellpoint's alleged failure to comply with those specific obligation(s). You may attach supporting materials or affidavit testimony.

You must complete and submit this petition no later than ninety (90) days after the Compliance Dispute first arose or after you first became aware of the Compliance Dispute to:

Compliance Dispute Facilitator
Cameron C. Staples
Neubert, Pepe & Monteith, P.C.
195 Church Street, 13th Floor
New Haven, CT 06510
Telephone: 203-821-2000
Fax: 203-821-2009
Email:Cstaples@npmlaw.com