CommentsThis field is for validation purposes and should be left unchanged. Christopher Daugherty, et al. v. Sarasota County Public Hospital District d/b/a Sarasota Memorial Health Care System Case No. 2019-CA-003178 NC Circuit Court of the Twelfth Judicial Circuit, In and For Sarasota County, Florida, Civil Division CLAIM FORM This field is hidden when viewing the formhiddenClaimantId*This field is hidden when viewing the formhiddenlastname*1. Contact InformationNotice ID*Name:* First Last Mailing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code PhoneEmail 2. AFFIRMATIONBy signing below, I certify that I was a (1) consumer patient residing in the State of Florida, who (2) was contacted at least once by Defendant Sarasota County Public Hospital District d/b/a Sarasota Memorial Healthcare System (“SMHCS”) regarding past-due emergency medical debt owed to SMHCS, which (3) may have exceeded the amount under the PIP coverage limitations under Florida law; (4) during the time period from June 7, 2017 to the May 6, 2026.Printed Name*Date* MM slash DD slash YYYY Unique IDClaimFormNo
