ONLINE CLAIM FORM

Please fill out the form below and we will review your potential claim at no cost or obligation.

Name:
  
Address:
  
City, State, Zip:
  
Day Phone:
  
Alt Phone:
 
Email Address:
  
Date of Implant:
 
Defibrillator Manufacturer / Model:
 
Lead 1 Model / Serial Number:
 
Lead 2 Model / Serial Number:
  
Lead 3 Model / Serial Number:
  
 
Briefly describe any problems you have experienced with your defibrillator
  
Additional Info/Comments:
 

DO YOU HAVE A RECALLED LEAD?

If you have a Sprint Fidelis lead, your Patient ID card should contain one of the following four sets of numbers:

6930 • 6931 • 6948 • 6949

(These numbers may be shown at the beginning of a longer set of numbers on your ID card.)

 

 

 

CONTACT INFORMATION

Robinson, Calcagnie & Robinson, INC.
620 Newport Center Drive - 7th Floor
Newport Beach, CA 92660
Phone: 1-888-701-1288