Claims Forms

Centralized Process for
Representative Appointment Attorneys’
Fee Dispute

Monetary Awards

Instructions for Claim Form

Request for Rescoring of Neuropsychological Test Results

MAF Claim Package Kit

Claim Form for Retired NFL Football Players and Representative Claimants

Monetary Award Claim Package HIPAA Authorization Form

MAF Diagnosing Physician Certification Form

Pre-Effective Date Diagnosing Physician Certification Form
(The deadline to submit any Pre-Effective Date claims expired on February 6, 2019)

SWS-2 (Diagnosing Physician Sworn Statement: Inability to Provide a Diagnosing Physician Certification)

SWS-3 (Third Party Sworn Statement: Functional Impairment)

SWS-4 (Sworn Statement by Retired NFL Football Player: Reasons for No Objective Evidence of Eligible Season(s))

Withdrawal of Monetary Award Claim

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Retired Player)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Knowledgeable Informant)

150-Mile Rule Exception Request Form

Stroke or Traumatic Brain Injury Explanation Form (for diagnosing physicians)

MAF Claim Package Kit

Claim Form for Retired NFL Football Players and Representative Claimants

Instructions

Monetary Award Claim Package HIPAA Authorization Form

MAF Diagnosing Physician Certification Form

Pre-Effective Date Diagnosing Physician Certification Form

SWS-2 (Diagnosing Physician Sworn Statement: Inability to Provide a Diagnosing Physician Certification Form)

SWS-3 (Third Party Sworn Statement: Functional Impairment)

SWS-4 (Sworn Statement by Retired NFL Football Player: Reasons for No Objective Evidence of Eligible Season(s))

Withdrawal of Monetary Award Claim

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Retired Player)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Knowledgeable Informant)

150-Mile Rule Exception Request Form

Stroke or Traumatic Brain Injury Explanation Form (for diagnosing physicians)

Derivative Claimant Awards

Instructions for Derivative Claim Form

Derivative Claim Form

Derivative Claimant HIPAA Authorization Form

Derivative Claim Form

Instructions

Derivative Claimant HIPAA Authorization Form

Supplemental Monetary Awards

Instructions for Supplemental Claim Form

Supplemental Claim Package Kit

Supplemental Claim Form for Retired NFL Football Players and Representative Claimants

Instructions

MAF Diagnosing Physician Certification Form

SWS-3 (Third Party Sworn Statement: Functional Impairment)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Retired Player)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Knowledgeable Informant)

150-Mile Rule Exception Request Form

Stroke or Traumatic Brain Injury Explanation Form (for diagnosing physicians)

Supplemental Claim Package Kit

Supplemental Claim Form for Retired NFL Football Players and Representative Claimants

MAF Diagnosing Physician Certification Form

SWS-3 (Third Party Sworn Statement: Functional Impairment)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Retired Player)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Knowledgeable Informant)

150-Mile Rule Exception Request Form

Stroke or Traumatic Brain Injury Explanation Form (for diagnosing physicians)

Most Viewed Forms

Claim Form for Retired NFL Football Players and Representative Claimants

Pre-Effective Date Diagnosing Physician Certification Form

MAF Diagnosing Physician Certification Form

Authorization for Release of Claims Information (Appendix A)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Retired Player)

Employment History and Social and Community Activity of Retired NFL Football Player (Form for Use by Knowledgeable Informant)

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