Note: Most of the text written in "light blue" below will take you to other web pages containing additional information, if you left click your mouse on it..


If you are a woman that was inserted with breast implants before June 1st of 1993, you may have a claim through your implant manufacturer.  To submit a breast implant claim, you will need to:

1.  Fill out a few forms.

2. Provide Proof of at least one breast implant that is covered under either:
    (a).  The current  MDL926 Revised Settlement (Bristol, Baxter, 3M or McGhan breast implants) or
           
    (b).  A breast implant manufactured by Dow Corning (Cronin, Silastic II, Varifil, Mueller V, MSI, MFP, NFP)
         
          Note:  Registration with the MDL926 Revised Settlement does not automatically register you with Dow.  Make sure that you are "Properly Registered"
                     with the Dow Corning Settlement Facility. This may include that you mail in both a "Proof of Claim" form and a
                    "Notice of Intent" Form, depending on the date that you registered. 
                                               

2.  Be evaluated by a doctor(s) who will determine if you meet the medical criteria.  These medical reports must
     also be sent in to support your claim.

     Note:  As a participant in either of the breast implant settlements, it is not necessary to prove "causation"
                (the implants caused my particular medical disability, as you would in a typical lawsuit).  Instead, you
                must meet certain requirements.  Then and only then will receive compensation from the manufacturer
                via the Claims Office.  However, should you decide to Opt-out of the upcoming Dow Settlement and
                file a lawsuit against them, you will have to prove that your implants caused your particular injury. 

Not sure what do do?

If you do have a qualifying set of breast implants, but are unsure whether you should pursue a breast implant claim, review the symptoms on this page.  You may find that you have more symptoms than you think. Then, fill out this free, no-obligation online questionnaire.  We will review the information and let you know whether or not you are eligible for benefits at no cost to you. 

If you wish for us to contact you by telephone, please include your phone number and the best time to reach you.  As a minimum, please include your email address, otherwise this form cannot operate properly.  After talking with you, we will send you out an information packet that will help you to get your claim started. 

As you may know, we are still accepting new clients for the proposed Dow Corning Settlement.  Also, we are still accepting new clients interested in filing a claim for Long-Term benefits under the under the current MDL926 Revised Settlement.  Should we accept you as a new client, there will be no attorney fee, unless we are able to recover a settlement for you.

Please fill out this form as completely as possible...  
 


  General Information

 Yes   No    Are you presently a client of Hummer Law Offices?

 Yes    No    Are you currently being represented by another attorney?

                              How did your hear about Hummer Law Offices? 


 Implant Information:
 

 Yes  No     Did you ever receive money from the MDL926 Claims Office, or from the
                               manufacturer of your breast implants?

                        If so, how much did you receive?   

 Yes  No    Have you ever registered with either the Global Settlement, the Revised Settlement or Dow?
                               If so, please tell us which settlement(s) you registered with, and the date that you registered in the 
                               space below.

                              

                               If you are registered, and know your "Status" under Revised Settlement, 
                               please indicate it here: 

Yes  No     Did you ever sign a form(s) which would release your implant manufacturer(s) from liability
                              when your implants were being  taken-out or replaced? (if such is the case, please tell us
                              about your implant history, and which manufacturer(s) were involved (use "additional
                              information" box at bottom of page) .  This will help us to better advise you of your rights.


                        

 Yes  No     Did you have at least one set of breast implants that were inserted in your body before
                              June 1, 1993?

                              If possible,  please tell us about your implant history.  This information will help us to
                              evaluate your claim faster.   Note: If you had only a "single" implant put in one breast, and
                              not a "set", please list it as if it was a set for this questionnaire.   We will get the full details at a
                              later time.

                              Manufacturer 1     

 Yes  No    Do you have "written proof" of your manufacturer for this 1st set?
                        (operative reports, implant labels, etc.)

                              If you would like more information about implant proof, click on one of the boxes below...
 
  Implants made by Dow Corning (Cronin, Silastic II, Varifil, Mueller V, MSI, MFP, NFP   Includes Bristol, MEC, Natural Y, Optiman, Replicon, Meme Surgitek, Vogue, Baxter, American Heyer-Schulte, 3M and McGhan breast implants


                        Manufacturer 2    

 Yes  No    Do you have "written proof" of your manufacturer for this 2nd set?  
 

                        Manufacturer 3   

 Yes  No    Do you have "written proof" of your manufacturer for this 3rd set?  
                                  

 Yes  No    Have you ever had one or more of your breast implants rupture?
 

  Please tell us about your eyes:

 Yes  No    Do you wear contact lenses?

 Yes  No    Do you experience morning irritation, or blurred vision?

 Yes  No    Do you experience excessive tearing?

 Yes  No    Do you experience itchy, burning or scratchy eyes?

 Yes  No    Have you had eyelid surgery?

  Tell us about your complexion:

 Yes  No    Do you have a flush or pink color in your cheeks?

 Yes  No     If so, does the pinkness get worse when you go out in the sun?
 

   Note:  In the last 2 questions, we asked about pinkness in the cheeks because we are looking for what is
                called a "malar" or "butterfly" rash.  This "sun-sensitive" rash tends to wax and wane, and is
                often associated with lupus.  For a definition of a malar rash for settlement purposes, click here.  If you
                would like to see a picture of women with a malar rash, click here.
 

  Other Symptoms:

 Yes  No     Do you have chronic fatigue?

 Yes  No     Do you have a dry mouth?

 Yes  No      Do you have joint pain?

 Yes  No     Do you have muscle pain?

 Yes  No     Any numbness or tingling in extremities (ex: arms, hands, fingers, legs, feet, toes)?

 Yes  No      Do you have memory loss?

 Yes  No      Do you have hair loss?
 Yes  No     Do you have bowel or bladder problems?
 
 Yes  No     Do you have any sleep disorders?
  
 Yes  No     Do you have night sweats or as low grade fever?

 Yes  No     Do you have cold hands and/or cold feet?

 Yes  No     Do you ever get sores in your mouth?

 Yes  No     Are you receiving Disability, Medicare or Medicaid benefits?
 

If there is any additional information that you would like to
tell us,  please list it here...

       
        Please tell us how to get in touch with you:

        Note: Our normal office hours are from 9:00am to 5:00pm Monday-Thursday EST.

Your Name
E-mail Address (required)
Home Phone #
Work / Alternate Phone # Extension 
Fax#
Best time to call you
Where are you contacting us from?
 
U.S. State:      Other Location:
 
        Would you like us to send you an information pack that contains all of the
        necessary claim forms and breast implant studies?       
 
        Yes, please send me an information packet (contains necessary claim forms, studies)
          No thank you, not at this time.
        Mailing Address:
        City: 
        State/Province:
        Postal Code:

          
       
         Please contact me as soon as possible regarding this matter.
 

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