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 800-291-6429 if you have any questions throughout the enrollment process.


Purpose of Agreement

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 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.


Terms and Conditions

The following serves as an Agreement that secures the services of MCAG, as outlined below, for assisting Client in Client’s participation under all current and future Settlements, and/or dispute resolutions resulting from Class Action litigation as approved by Client and MCAG including the In re Payment Card Interchange Fee and Merchant Discount Antitrust Litigation, MDL No. 1720 ("Visa/MC Settlement"). This enrollment form authorizes MCAG to accept Client’s information as required by the Settlements, which could include, but will not be limited to, claims data, transactional data and financial information. Client appoints MCAG as exclusive Recovery Agent with full assignment authority to represent its interests and submit a claim under the terms of each agreed upon Class Action Settlement for which Client is an eligible class member directly to the Settlement Administrator on Client’s behalf.

MCAG will utilize its best efforts to: a.) determine Client eligibility for reimbursement from the Settlements, and b.) prepare and submit a claim for reimbursement under the terms of the Settlements or dispute resolutions related thereto.

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 made available 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 commercially reasonable 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 provides 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.

MCAG may require additional information from Client in the future in order to meet requirements for a specific settlement. Therefore, MCAG may not be able to submit a claim if Client does not provide additional information as instructed in future communications from MCAG.

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.

Termination

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.
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.

Confidentiality/Non-Disclosure

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

MCAG performs its Recovery Services for a percentage of actual recoveries achieved for clients. MCAG will retain or Client will pay MCAG a fee of thirty percent (30%) of recoveries received by Client from Class Action Settlements and/or Dispute Resolutions.

Definitions for terms found in the Agreement:


Payment Card Interchange Fee Settlement (Visa/MasterCard) Disclaimer: The Second Circuit Court of Appeals reversed approval of the settlement and returned the case to the District Court on June 30, 2016. Litigation is ongoing. No claim forms are available at this time, and no claim-filing deadline exists. If another settlement is reached, 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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