Enrollment Form

Once you begin the enrollment process, you are not able to save the form and return to it later. So, if you have multiple locations and merchant IDs (MIDs), we suggest that you compile all necessary documentation before beginning the enrollment process. For each MID, we’ll ask for the applicable business name, address, tax ID, payment processor name, and approximate dates with the processor.

If you do not want to spend the time entering all of this information now, you can simply enroll your primary location and download a template for your additional information to be uploaded later. Clicking here will redirect you to the location where you can download the template and upload it once it is completed.

Please contact an MCAG representative at 855-761-2913 if you have any questions throughout the enrollment process.

This Agreement is entered into as of the submission date of the electronic form found below ("Effective Date"), by and on behalf of Client/Business/Organization Name ("Client") provided below and Managed Care Advisory Group, LLC ("MCAG") with principal residence at 3434 Granite Circle, Toledo, OH 43617 for the purposes set forth below.

Purpose of Agreement

This Agreement secures the services of MCAG to file Client’s claim in any class action settlement which MCAG identifies and/or of which MCAG has been made aware, with the exception of (i) those class actions in which Client has opted out of the class, (ii) any class action where Client instructs MCAG in writing not to file a claim on Client’s behalf, or (iii) any class action where MCAG determines that it is not advisable to pursue on Client’s behalf (collectively, the “Settlement(s)”). Client authorizes MCAG to accept Client’s information as required by the Settlement, which could include, but will not be limited to, claims data, transactional data and financial information. Client appoints MCAG as exclusive Recovery Agent, defined as a contractually authorized third-party filing agent with full assignment authority to represent its interest, execute the claim form and submit a claim under the terms of this Agreement in the Settlements for which Client is an eligible Class Member directly to the Settlement Administrator on Client’s behalf.

Terms and Conditions

MCAG will utilize its best efforts to: a.) determine Client eligibility for reimbursement from the Settlements, b.) prepare and submit a claim for reimbursement under the terms of the Settlements or dispute resolutions related thereto, c.) retain the services on Client’s behalf of an attorney, accountant, or other representative strictly for the specific purposes of the Settlements as required by the Settlements and deemed appropriate by MCAG.

MCAG will file a claim based on the information provided by the Client, and/or any information made available to MCAG by the Settlement Administrator, and/or any data MCAG is able to obtain from third party repositories, which may include, but is not limited to, billing and payment clearinghouses and processors, attorneys, accountants, and other outlets as required by the Settlements. MCAG will submit the claims, collect the returns, and distribute the net payments to Client.

MCAG warrants that it will use its best efforts to file claims on behalf of Client and to help Client maximize the return available to Client under the Settlements. However, due to the complexity of the terms and provisions of the Settlements and due to the authority given the Settlement Administrator to determine eligible reimbursement under the Settlements, MCAG cannot warrant or guarantee the dollar amount, if any, returned to Client through the Settlement process.

Client will use its best efforts to facilitate the efforts of MCAG to collect and submit data/information required for participation by Client in the Settlements. Client understands and agrees that MCAG may not be able to file a claim on behalf of Client if Client is not able to provide all required data/information. Client agrees that MCAG has no liability for information provided by Client as part of the Settlement claim filing process, and Client will be held solely responsible if any information it supplies is found to be inaccurate. Client authorizes MCAG to access and collect data/information relevant to the Settlements from Client and any appropriate third parties to file claims, collect recoveries, and extract the service fees as outlined in the “Service Fee” section of this Agreement from the recoveries, and return net recoveries to Client.

The initial term of this Agreement (“Term”) shall commence on the Effective Date and shall continue in full force and effect for a period of three (3) years, unless earlier terminated as hereinafter provided. The Term shall renew automatically for additional periods of one year each, unless canceled as set forth in the Termination Section of this Agreement. If MCAG has submitted a claim on behalf of Client for any Settlement(s) prior to the effective date of a written Notice of Termination, then MCAG shall complete the process for recovering any settlement amounts, providing its Services and making any payment(s) to Client, and collecting and/or retaining any Service Fees in accordance with the provisions of this Agreement.

This Agreement is meant to cover all of the Client's subsidiaries and locations, and shall be binding upon and shall inure to benefit of MCAG and the Client and to the Client’s successors and assigns. Nothing in this Agreement shall be construed to permit the assignment by MCAG or Client of any of its rights or obligations hereunder, and such assignment is expressly prohibited without the prior written consent of MCAG or Client, as applicable.


This Agreement may be terminated at any time with or without cause provided notice of termination is provided in writing at least ninety (90) days in advance of the desired date of termination.


MCAG and Client recognize the need to maintain strict confidentiality regarding business processes, financial information, Personal Health Information (PHI as defined in HIPAA), tax records, profit and loss reports and any information received from the other party.

The Parties shall not, at any time, directly or indirectly, divulge, distribute, publish, disclose, communicate, or otherwise disseminate to any individual, corporation or other entity, or divert Proprietary Information, Client Information and the information described below, in whole or in part, or utilize such information for any purpose, other than the purposes so defined and agreed to by the Parties in this Agreement, in any manner whatsoever: a) the whole or any portion or phase of any Trade Secrets and other information related to the examination, review or auditing of or recovery of Client billing/payment records or related to billing, legal or financial services performed for Clients, b) any business information or plans, financial information, or listing of names, addresses (including e-mail) or telephone numbers of either Party or the Client that is not generally known to persons not affiliated with Party or Clients, and/or, c) any information treated as or considered to be secret, confidential or proprietary pursuant to any agreement between the Parties and any other entities.

The term “Confidential Information” means any data or information of either MCAG or the Client which is valuable to either the Client or MCAG and not generally known to competitors of either Party.

Service Fee

Client agrees to pay MCAG a fee of thirty percent (30%) (“Commission”) of Client’s aggregate gross recovery received as payment for the Settlement claim(s) filed by MCAG on behalf of Client without deduction for any expenses of MCAG (“Gross Recovery”) pursuant to this Agreement. MCAG’s Commission is contingent upon Client receiving proceeds and if Client receives no proceeds, for any reason, MCAG is not entitled to a Commission. MCAG’s Commission is all-inclusive and no expenses will be charged to Client. Client understands that for many Settlements, the Gross Recovery will be paid to MCAG, deposited into a MCAG account and MCAG will deduct its Commission before distributing the Client’s share.


This Agreement contains the entire agreement of the parties. The invalidity of one provision of this Agreement shall not affect any other provision. This Agreement shall be construed in accordance with and governed by the laws of the State of Ohio.

Definitions for terms found in the Agreement:

Payment Card Settlement (Visa/MC) Disclaimer: The Rule 23(b)(3) Class Plaintiffs have reached a proposed settlement in this action.  Materials reflecting this proposed settlement were filed September 18, 2018 with the Court. No claim forms are available at this time, and no claim-filing deadline exists. If the settlement is approved, no-cost assistance will be available from the Class Administrator and Class Counsel during any claims-filing period. No one is required to sign up with any third-party service in order to participate in any settlement. For additional information regarding the status of the litigation, interested persons may visit www.paymentcardsettlement.com, the Court-approved website for this case.

Enrollment Form

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