You are on page 1of 47

NFL CONCUSSION SETTLEMENT

PROGRAM: QUALIFIED MAF PHYSICIAN


MANUAL
As of 4/20/17

https://www.nflconcussionsettlement.com/Home.aspx

NFLQualifiedMAFPhysicians@NFLConcussionSettlement.com

1-855-887-3485

© 2017 BrownGreer PLC


522331
4/20/17
TABLE OF CONTENTS

A. Introduction......................................................................................................................................1
B. Qualifying Diagnoses. ......................................................................................................................1
1. Level 1.5 Neurocognitive Impairment (Early Dementia) ...................................................... 2
2. Level 2 Neurocognitive Impairment (Moderate Dementia) .................................................. 3
3. Alzheimer’s Disease .................................................................................................................. 3
4. Parkinson’s Disease .................................................................................................................. 4
5. Amyotrophic Lateral Sclerosis (ALS) ..................................................................................... 4
C. Neuropsychological Testing Protocol for Level 1.5 and Level 2 Neurocognitive Impairment.....4
D. Diagnosing Physician Certification and Medical Records. ......................................................... 9
1. Provider Portal .......................................................................................................................... 9
2. Online Upload...........................................................................................................................10
3. Mail or Delivery .......................................................................................................................10
E. Independent Examination and Review of Medical Records. .....................................................11
Appendix A: Third Party Sworn Affidavit .......................................................................................12
Appendix B: Diagnosing Physician Certification Form ...................................................................17
Appendix C: MAF Diagnosing Physician Certification Form ……………………………........... 37

Appendix D: Monetary Award Claim Package HIPAA Authorization Form ……….…............ 42

© 2017 BrownGreer PLC


522331
4/20/17
This Qualified MAF Physician Manual explains the role of a Qualified MAF Physician in the
NFL Concussion Settlement Program and describes how Qualified MAF Physicians can
complete and submit the Diagnosing Physician Certification Form and supporting medical
records to the Claims Administrator.

A. Introduction.

A Qualified MAF Physician is a board-certified neurologist, board-certified neurosurgeon, or


other board-certified neuro-specialist physician, who is part of an approved list of physicians
authorized to make Qualifying Diagnoses under the terms of the NFL Concussion Settlement
Agreement (the “Settlement”). You have been selected and approved to serve as a Qualified
MAF Physician for the Settlement in part because you meet the following requirements:

1. Possess a current, active, unrestricted state license;


2. Hospital staff privileges are not revoked and have not been restricted within the past five
years;
3. Are covered by proper insurance under state law;
4. Are not excluded from participation in any federal or state healthcare program;
5. Medical license has not been subject to any disciplinary action or any restrictions within
the past five years;
6. Were never convicted of a crime of dishonesty; and
7. Have not served on or after April 22, 2015, as a litigation expert consultant or expert
witness for a Retired NFL Football Player who has opted out of the Settlement, or his, her
or its counsel, in connection with litigation relating to the injuries and/or conduct
addressed in the In re National Football League Players’ Concussion Injury Litigation.
The list of Retired NFL Football Players who have opted out of the Settlement can be
found on the Settlement Program website by clicking on this link:
https://www.nflconcussionsettlement.com/CourtDocs.aspx.

You must notify the Claims Administrator in writing immediately if you no longer meet any of
these requirements, or if you are alleged to have committed, are charged with, are named as a
defendant in a civil action involving, or are convicted of or found guilty of a crime of dishonesty,
an act of violence, or moral turpitude. Email your written notification to
NFLQualifiedMAFPhysicians@NFLConcussionSettlement.com or mail it to:

NFL Concussion Settlement


Claims Administrator
P.O. Box 25369
Richmond, VA 23260

B. Qualifying Diagnoses.

As a Qualified MAF Physician, you may be contacted by Retired NFL Football Players seeking a
Qualifying Diagnosis, which in turn allows them to submit a claim for a Monetary Award. This
section describes each of these Qualifying Diagnoses. For each one, the identification of a
condition, including through a blood test, genetic test, imaging technique, or otherwise, that has

1 of 45
not yet resulted in actual cognitive impairment and/or actual neuromuscular impairment
experienced by the patient does not qualify as a Qualifying Diagnosis.

If you require assistance by a neuropsychologist in diagnosing the Qualifying Diagnosis of a


player, that neuropsychologist must be certified by the American Board of Clinical
Neuropsychology (ABCN), which is a member of the American Board of Professional
Psychology (ABPP), pursuant to the requirements in Section 6.3(b)(i) of the Settlement
Agreement. You should also provide the neuropsychologist who assists in the testing with the
Clinician’s Interpretation Guide, provided here as Appendix B.

1. Level 1.5 Neurocognitive Impairment (Early Dementia). Qualifying Diagnoses of


Level 1.5 Neurocognitive Impairment (i.e., early dementia) must be made while the
Retired NFL Football Player is living and be based on evaluation and evidence generally
consistent with the following diagnostic criteria:

(a) Concern of severe decline in cognitive function: Concern of the Retired NFL
Football Player, a knowledgeable informant, or the Qualified MAF Physician that
there has been a severe decline in cognitive function.
(b) Evidence of moderate to severe decline: Evidence of a moderate to severe
cognitive decline from a previous level of performance, as determined by and in
accordance with the standardized neuropsychological testing protocol described in
Section C of this Manual, in two or more cognitive domains (complex attention,
executive function, learning and memory, language, perceptual-spatial), provided one
of the cognitive domains is (1) executive function, (2) learning and memory, or (3)
complex attention.
(c) Functional impairment: The Retired NFL Football Player exhibits functional
impairment generally consistent with the criteria set forth in the National Alzheimer’s
Coordinating Center’s Clinical Dementia Rating (CDR) scale Category 1.0 (Mild) in
the areas of Community Affairs, Home & Hobbies, and Personal Care. Such
functional impairment shall be corroborated by documentary evidence (e.g., medical
records, employment records), the sufficiency of which will be determined by the
physician making the Qualifying Diagnosis. In the event that no documentary
evidence of functional impairment exists or is available, then (1) there must be
evidence of moderate to severe cognitive decline from a previous level of
performance, as determined by and in accordance with the standardized
neuropsychological testing protocol described in Section C of this Manual, in the
executive function cognitive domain or the learning and memory cognitive domain,
and at least one other cognitive domain; and (2) the Retired NFL Football Player’s
functional impairment, as described above, must be corroborated by a third-party
sworn affidavit1 from a person familiar with the Retired NFL Football Player’s
condition (other than the player or his family members), the sufficiency of which will
be determined by the physician making the Qualifying Diagnosis.

1
A template for this Third Party Sworn Statement: Functional Impairment is attached to this Manual as Appendix A.

2 of 45
(d) Not exclusively in context of a delirium, acute substance abuse, or as a result of
medication side effects: The cognitive deficits do not occur exclusively in the
context of a delirium, acute substance abuse, or as a result of medication side effects.
2. Level 2 Neurocognitive Impairment (Moderate Dementia). Qualifying Diagnoses of
Level 2 Neurocognitive Impairment (i.e., moderate dementia) must be made while the
Retired NFL Football Player is living and be based on evaluation and evidence generally
consistent with the following diagnostic criteria, unless certain testing is medically
unnecessary because the Retired NFL Football Player’s dementia is so severe:
(a) Concern of severe decline in cognitive function: Concern of the Retired NFL
Football Player, a knowledgeable informant, or the Qualified MAF Physician that
there has been a severe decline in cognitive function.
(b) Evidence of severe decline: Evidence of a severe cognitive decline from a previous
level of performance, as determined by and in accordance with the standardized
neuropsychological testing protocol described in Section C of this Manual, in two or
more cognitive domains (complex attention, executive function, learning and
memory, language, perceptual-spatial), provided one of the cognitive domains is (1)
executive function, (2) learning and memory, or (3) complex attention.
(c) Functional impairment: The Retired NFL Football Player exhibits functional
impairment generally consistent with the criteria set forth in the National Alzheimer’s
Coordinating Center’s Clinical Dementia Rating (CDR) scale Category 2.0
(Moderate) in the areas of Community Affairs, Home & Hobbies, and Personal Care.
Such functional impairment shall be corroborated by documentary evidence (e.g.,
medical records, employment records), the sufficiency of which will be determined
by the physician making the Qualifying Diagnosis. In the event that no documentary
evidence of functional impairment exists or is available, then (1) there must be
evidence of severe cognitive decline from a previous level of performance, as
determined by and in accordance with the standardized neuropsychological testing
protocol described in Section C of this Manual, in the executive function cognitive
domain or the learning and memory cognitive domain, and at least one other
cognitive domain; and (2) the Retired NFL Football Player’s functional impairment,
as described above, must be corroborated by a third-party sworn affidavit2 from a
person familiar with the Retired NFL Football Player’s condition (other than the
player or his family members), the sufficiency of which will be determined by the
physician making the Qualifying Diagnosis.

(d) Not exclusively in context of a delirium, acute substance abuse, or as a result of


medication side effects: The cognitive deficits do not occur exclusively in the
context of a delirium, acute substance abuse, or as a result of medication side effects.
3. Alzheimer’s Disease. A Qualifying Diagnosis of Alzheimer’s Disease must be made
while the Retired NFL Football Player is living and must be a diagnosis of:

2
A template for this Third Party Sworn Statement: Functional Impairment is attached to this Manual as Appendix A.

3 of 45
(a) The specific disease of Alzheimer’s Disease as defined by the World Health
Organization’s International Classification of Diseases, 9th Edition (ICD-9), the
World Health Organization’s International Classification of Diseases, 10th Edition
(ICD-10); or
(b) A diagnosis of Major Neurocognitive Disorder due to probable Alzheimer’s Disease
as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
4. Parkinson’s Disease. A Qualifying Diagnosis of Parkinson’s Disease must be made
while the Retired NFL Football Player is living and must be a diagnosis of:

(a) The specific disease of Parkinson’s Disease as defined by the World Health
Organization’s International Classification of Diseases, 9th Edition (ICD-9), the
World Health Organization’s International Classification of Diseases, 10th Edition
(ICD-10); or
(b) A diagnosis of Major Neurocognitive Disorder probably due to Parkinson’s Disease
as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
5. Amyotrophic Lateral Sclerosis (ALS). A Qualifying Diagnosis of ALS must be made
while the Retired NFL Football Player is living and must be a diagnosis of the specific
disease of Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s Disease, as
defined by the World Health Organization’s International Classification of Diseases, 9th
Edition (ICD-9) or the World Health Organization’s International Classification of
Diseases, 10th Edition (ICD-10).

C. Neuropsychological Testing Protocol for Level 1.5 and Level 2 Neurocognitive


Impairment.

This section describes the standardized neuropsychological testing protocol mentioned in Section
B of this Manual for the Qualifying Diagnoses of Level 1.5 and Level 2 Neurocognitive
Impairment, as detailed in the Clinician’s Interpretation Guide. The testing completed should be
generally consistent with these criteria and certain testing may be medically unnecessary in cases
of Level 2 Neurocognitive Impairment because the Retired NFL Football Player’s dementia is so
severe. If you require assistance by a neuropsychologist in performing any of these tests, the
neuropsychologist must—as explained in Section B—meet the requisite certification
requirements and should be provided with a copy of the Clinician’s Interpretation Guide to
follow when administering the below testing protocol.

4 of 45
Section 1: Test Battery
Estimating Premorbid Intellectual
Learning and Memory (6 scores)
Ability
ACS Test of Premorbid Functioning
WMS-IV Logical Memory I
(TOPF)
Complex Attention/Processing Speed (6
WMS-IV Logical Memory II
scores)
WAIS-IV Digit Span WMS-IV Verbal Paired Associates I
WAIS-IV Arithmetic WMS-IV Verbal Paired Associates II
WAIS-IV Letter Number Sequencing WMS-IV Visual Reproduction I
WAIS-IV Coding WMS-IV Visual Reproduction II
WAIS-IV Symbol Search Language (3 scores)
WAIS-IV Cancellation Boston Naming Test
Executive Functioning (4 scores) Category Fluency (Animal Naming)
Verbal Fluency (FAS) BDAE Complex Ideational Material
Trails B Spatial-Perceptual (3 scores)
Booklet Category Test WAIS-IV Block Design
WAIS-IV Similarities WAIS-IV Visual Puzzles
Performance Validity (8 scores) WAIS-IV Matrix Reasoning
ACS Scores Mental Health
ACS-WAIS-IV Reliable Digit Span MMPI-2RF
ACS-WMS-IV Logical Memory Mini International Neuropsychiatric
Recognition Interview
ACS-WMS-IV Verbal Paired Associates
Recognition
ACS-WMS-IV Visual Reproduction
Recognition
ACS-Word Choice
Additional Performance Validity Tests
Test of Memory Malingering (TOMM)
Medical Symptom Validity Test
(MSVT)

Section 2: Evaluate Performance Validity


Freestanding, embedded and regression based performance validity metrics will be administered
to each Retired NFL Football Player during the evaluation. The Clinician’s Interpretation Guide
provides specific guidance on the administration of this assessment.

5 of 45
Section 3: Estimate Premorbid Intellectual Ability
Test Ability
Reading
Test of Premorbid Functioning (TOPF)
Reading + Demographic Variables
The Test of Premorbid Functioning (TOPF) provides three models for predicting premorbid
functioning: (a) demographics only, (b) TOPF only, and (c) combined demographics and
TOPF prediction equations. For each model using demographic data, a simple and complex
prediction equation can be selected. In the simple model, only sex, race/ethnicity, and
education, are used in predicting premorbid ability. In the complex model, developmental,
personal, and more specific demographic data is incorporated into the equations. The clinician
should select a model based on the patient’s background and his or her current level of reading
or language impairment.

Note: It is necessary to estimate premorbid intellectual functioning in order to use the criteria
for impairment set out in this document. Estimated premorbid intellectual ability will be
assessed and classified as:

➢ Below Average (estimated IQ below 90);

➢ Average (estimated IQ between 90 and 109);

➢ Above Average (estimated IQ above 110).

Section 4: Neuropsychological Test Score Criteria by Domain of Cognitive Functioning


There are 5 domains of cognitive functioning. In each domain, there are several tests that
contribute 3, 4, or 6 demographically-adjusted test scores for consideration. Test selection in
the domains was based on the availability of demographically-adjusted normative data for
Caucasians and African Americans. These domains and scores are set out below.

The basic principle for defining impairment on testing is that there must be a pattern of
performance that is approximately 1.5 standard deviations (for Level 1 Impairment), 1.7-1.8
standard deviations (for Level 1.5 Impairment) or 2 standard deviations (for Level 2
Impairment) below the person’s expected level of premorbid functioning. Therefore, it is
necessary to have more than one low test score in each domain. The Clinician’s Interpretation
Guide sets out the cutoff scores, criteria for identifying impairment in each cognitive domain,
and statistical and normative data to support the impairment criteria.
Domain/Test Ability
Complex Attention/Speed of Processing (6
Scores)
Digit Span Attention & Working Memory

6 of 45
Domain/Test Ability
Arithmetic Mental Arithmetic
Letter Number Sequencing Attention & Working Memory
Coding Visual-Processing & Clerical Speed
Symbol Search Visual-Scanning & Processing Speed
Cancellation Visual-Scanning Speed
Executive Functioning (4 scores)
Similarities Verbal Reasoning
Verbal Fluency (FAS) Phonemic Verbal Fluency
Trails B Complex Sequencing
Booklet Category Test Conceptual Reasoning
Learning and Memory (6 scores)
Logical Memory I Immediate Memory for Stories
Logical Memory II Delayed Memory for Stories
Verbal Paired Associates I Learning Word Pairs
Verbal Paired Associates II Delayed Memory for Word Pairs
Visual Reproduction I Immediate Memory for Designs
Visual Reproduction II Delayed Memory for Designs
Language
Boston Naming Test Confrontation Naming
BDAE Complex Ideational Material Language Comprehension
Category Fluency Category (Semantic) Fluency
Visual-Perceptual
Block Design Spatial Skills & Problem Solving
Visual Puzzles Visual Perceptual Reasoning
Matrix Reasoning Visual Perceptual Reasoning
Impairment Criteria: Below Average Estimated Intellectual Functioning (A1 – E1)
A1. Complex Attention (6 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 35
2. Level 1.5 Impairment: 4 or more scores below a T score of 35; or meet for Level 1 and
2 scores below a T score of 30
3. Level 2 Impairment: 3 or more scores below a T score of 30
B1. Executive Function (4 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: 3 or more scores below a T score of 35; or meet for Level 1 and
1 score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30
C1. Learning and Memory (6 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 35
2. Level 1.5 Impairment: 4 or more scores below a T score of 35; or meet for Level 1 and
2 scores below a T score of 30

7 of 45
3. Level 2 Impairment: 3 or more scores below a T score of 30
D1. Language (3 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 37
2. Level 1.5 Impairment: meet for Level 1 and 2 scores below a T score of 35
3. Level 2 Impairment: 3 or more scores below a T score of 35
E1. Visual-Perceptual (3 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 37
2. Level 1.5 Impairment: meet for Level 1 and 2 scores below a T score of 35
3. Level 2 Impairment: 3 or more scores below a T score of 35
Impairment Criteria: Average Estimated Intellectual Functioning (A2 – E2)
A2. Complex Attention (6 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: 3 or more scores below a T score of 35; or meet for Level 1 and
1 score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30
B2. Executive Function (4 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: 3 or more scores below a T score of 35; or meet for Level 1 and
1 score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30
C2. Learning and Memory (6 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 35
2. Level 1.5 Impairment: 4 or more scores below a T score of 35; or meet for Level 1 and
1 score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30
D2. Language (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 37
2. Level 1.5 Impairment: 3 or more scores below a T score of 37; or meet for Level 1 and
1 score below a T score of 35
3. Level 2 Impairment: 2 or more scores below a T score of 35
E2. Visual-Perceptual (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 37
2. Level 1.5 Impairment: 3 or more scores below a T score of 37; or meet for Level 1 and
1 score below a T score of 35
3. Level 2 Impairment: 2 or more scores below a T score of 35
Impairment Criteria: Above Average Estimated Intellectual Functioning (A3 – E3)
A3. Complex Attention (6 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: meet for Level 1 and 3 or more scores below a T score of 37
3. Level 2 Impairment: 3 or more scores below a T score of 35
B3. Executive Function (4 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 37
2. Level 1.5 Impairment: meet for Level 1 and 3 or more scores below a T score of 37; or
meet for Level 1 and 1 score below a T score of 30

8 of 45
3. Level 2 Impairment: 2 or more scores below a T score of 30
C3. Learning and Memory (6 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: meet for Level 1 and 3 or more scores below a T score of 37
3. Level 2 Impairment: 3 or more scores below a T score of 35
D3. Language (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 40
2. Level 1.5 Impairment: 3 scores below at T score of 40; or meet for Level 1 and 1 score
below a T score of 37
3. Level 2 Impairment: 2 or more scores below a T score of 37
E3. Visual-Perceptual (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 40
2. Level 1.5 Impairment: 3 scores below at T score of 40; or meet for Level 1 and 1 score
below a T score of 37
3. Level 2 Impairment: 2 or more scores below a T score of 37

Section 5: Mental Health Assessment

Test Symptoms/Functioning Assessment


Evaluation of Validity Scales
and Configurations;
MMPI-2RF Mental Health Assessment
T-Scores for Symptom
Domains
Mini International
Semi-structured Psychiatric Scale Criteria for Various
Neuropsychiatric Interview
Interview Psychiatric Diagnoses
(M.I.N.I. Version 5.0.0)

D. Diagnosing Physician Certification Form and Supporting Medical Records.


If you examine a Retired NFL Football Player and determine that he has a Qualifying Diagnosis,
you must document that Qualifying Diagnosis by completing and submitting to the Claims
Administrator (1) an MAF Diagnosing Physician Certification Form in the form attached to this
Manual as Appendix C and (2) all medical records supporting that Qualifying Diagnosis. There
are two methods by which you may submit these documents to the Claims Administrator:

1. Provider Portal. The most efficient and secure method for completing the Diagnosing
Physician Certification Form and submitting it and the Retired NFL Football Player’s
medical records to the Claims Administrator is through your secure Provider Portal
account. If you would like to set up a Provider Portal account, contact the Claims
Administrator by phone at 1-855-887-3485 or by email at
NFLQualifiedMAFPhysicians@NFLConcussionSettlement.com. The Claims
Administrator will set up your account and provide detailed instructions to help you log
in and navigate your Provider Portal.

9 of 45
After you log into your Provider Portal, you will be able to search for the Retired NFL
Football Player for whom you wish to complete a Diagnosing Physician Certification
Form by entering the player’s name and date of birth or social security number. After
you select the Retired NFL Football Player, his information will be pre-filled in the
online Diagnosing Physician Certification Form. All you need to do is identify any
neuropsychologist who assisted you in making the Qualifying Diagnosis, select the
Qualifying Diagnosis and enter the date of that diagnosis, and then type in your electronic
signature to certify that the information provided is true and correct to the best of your
knowledge, information and belief. Then submit the completed Diagnosing Physician
Certification Form to the Claims Administrator. You also will be able to upload the
Retired NFL Football Player’s medical records through your secure Provider Portal and
submit them directly to the Claims Administrator without the hassle and expense of
printing and postage.
The Claims Administrator will provide you with detailed step-by-step instructions for
using your Provider Portal to submit the Diagnosing Physician Certification Form and
supporting medical records and will make these instructions available on your Provider
Portal at all times.

2. Online Upload. If you are unable to use the Provider Portal but still prefer to submit the
Diagnosing Physician Certification Form and supporting medical records electronically,
contact the Claims Administrator by phone at 1-855-887-3485 or by email at
NFLQualifiedMAFPhysicians@NFLConcussionSettlement.com, and we will provide
you with a link to a webpage. This webpage contains an upload button that allows you
securely to upload your completed Diagnosing Physician Certification and supporting
medical records to the Claims Administrator without logging into the Provider Portal
with a user name and password. To upload documents from this webpage, you will need
to enter your National Provider Identifier so we can verify that you are a Qualified MAF
Physician eligible to upload these documents.
Although this upload method allows you to avoid printing and postage costs by
submitting these documents electronically, you will have to complete all sections of the
Diagnosing Physician Certification Form either by typing the information into the fillable
PDF provided to you by the Claims Administrator, or by printing a hard copy, filling it
out by hand, and then scanning and uploading it to your computer. These are extra steps
that can be avoided by logging into the secure Provider Portal and filling out the
Diagnosing Physician Certification Form online.

3. Mail or Delivery. If you are unable to use a computer to submit the Diagnosing
Physician Certification Form and supporting medical records online, you may choose to
submit hard copies of those documents to the Claims Administrator by mail or delivery.
If you choose this method, the Claims Administrator will not reimburse you for printing,
postage, or delivery costs.
Mail the completed and signed Diagnosing Physician Certification Form and copies of
the supporting medical records to the Claims Administrator at this address:

10 of 45
NFL Concussion Settlement
Claims Administrator
P.O. Box 25369
Richmond, VA 23260

Or, have them delivered to this address:

NFL Concussion Settlement


c/o BrownGreer PLC
250 Rocketts Way
Richmond, VA 23231

The Order Regarding Retention, Exchange, and Confidentiality of Claims Information in NFL
Concussion Settlement Program, entered by Judge Anita Brody on March 23, 2017, authorizes
Qualified MAF Physicians to release medical records and information to the Claims
Administrator. However, if you require an authorization from the Retired NFL Football Player
or his representative before you will release medical records and information to the Claims
Administrator, have him or her complete and sign the Monetary Award Claim Package HIPAA
Authorization Form attached to this Manual as Appendix D.

E. Independent Examination and Review of Medical Records.


In some rare cases, the diagnosing physician who provided the Qualifying Diagnosis to the
Retired NFL Football Player may have died or become legally incapacitated or incompetent
before the physician was able to complete a Diagnosing Physician Certification Form. In such
cases, the Retired NFL Football Player may ask you to perform an independent examination and
review the medical records that formed the basis of the prior Qualifying Diagnosis. If this
happens, and you agree with the prior Qualifying Diagnosis, the date of the Qualifying Diagnosis
you enter on the Diagnosing Physician Certification Form should be the date of the prior
Qualifying Diagnosis by the deceased or legally incapacitated or incompetent physician and not
the date of your independent examination of the Retired NFL Football Player and his medical
records.

11 of 45
Appendix A

Third Party Sworn Statement: Functional Impairment

12 of 45
SWS-3 THIRD-PARTY SWORN STATEMENT: FUNCTIONAL IMPAIRMENT
This Sworn Statement is to be used by a person, other than a Retired NFL Football Player or his family
member, who personally knows the Retired NFL Football Player, is familiar with his condition, and can
describe his functional impairment in the areas of Community Affairs, Home & Hobbies, and Personal
Care (see next page for detailed instructions). This document is to be used by Settlement Class Members
seeking to corroborate the Retired NFL Football Player’s functional impairment when no documentary
evidence (for example, medical records or employment records) exists or is available.

I. RETIRED NFL FOOTBALL PLAYER INFORMATION

Settlement Program ID
| | | | | | | | | |
First M.I. Last
Retired NFL Football
Player Name
Retired NFL Football | | |/| | |/| | | | |
Player Date of Birth (Month/Day/Year)

II. THIRD-PARTY INFORMATION


First M.I. Last
Name
Street/P.O. Box

Mailing Address City State Zip

Telephone | | | |-| | | |-| | | | |

E-Mail Address
Relation to the Retired
NFL Football Player

www.NFLConcussionSettlement.com
522453 Page 1 of 4 4/19/17
SWS-3 THIRD-PARTY SWORN STATEMENT: FUNCTIONAL IMPAIRMENT
III. DESCRIPTION OF RETIRED NFL FOOTBALL PLAYER’S FUNCTIONAL IMPAIRMENT
In your own words, describe any behavior of the Retired NFL Football Player listed on the first page of
this form that you believe demonstrates difficulties he has in his everyday functioning. We would like you
to comment on each of the following areas:

 Community Affairs (how he functions in the community, outside the home)


 Home & Hobbies (how he functions at home)
 Personal Care (how he takes care of himself)

Also explain how you are aware of the above-described difficulties, if any.

Examples of the types of activities in each of these categories are listed here, and range in severity.
These include:

 Community Affairs
- Loss of interest in activities outside the home
- Inability to perform occupational activities (employment)
- Loss of the ability to drive
- Failure to shop for himself
- Has stopped visiting with friends and family
- Has stopped attending church, social functions, political activities, every day appointments, or
educational programs
- Has repeated conflicts with strangers.

 Home & Hobbies


- Difficulties getting along with family members
- Inability to perform household chores, such as cooking, laundry, vacuuming, cleaning, making
the bed, taking out the garbage, yard work, and basic home repair
- Loss of interest in hobbies, such as painting, reading, entertaining, photography, gardening,
woodworking, or participation in sports.

 Personal Care
- Decline in appearance
- Loss of the ability to dress himself
- Lapses in washing and grooming
- Decline in eating habits (for example, no longer eats regular meals, or in more severe cases
has trouble with using utensils and has to be fed)
- Poor toileting habits or loss of bladder control (for example, soils himself or wets the bed).

Use the space below to describe the player’s function in each of these areas. If you need more space,
attach additional pages.

www.NFLConcussionSettlement.com
522453 Page 2 of 4 4/19/17
SWS-3 THIRD-PARTY SWORN STATEMENT: FUNCTIONAL IMPAIRMENT

www.NFLConcussionSettlement.com
522453 Page 3 of 4 4/19/17
SWS-3 THIRD-PARTY SWORN STATEMENT: FUNCTIONAL IMPAIRMENT
IV. SIGNATURE

This Sworn Statement is an official document submitted in connection with the Class Action Settlement in
In re: National Football League Players’ Concussion Injury Litigation, MDL No. 2323. By signing below,
I declare under penalty of perjury, pursuant to 28 U.S.C. § 1746, that all information provided in
this Sworn Statement is true and correct to the best of my knowledge, information and belief.

Third-Party Signature Date | | |/| | |/| | | | |


(Month/Day/Year)

First M.I. Last

Printed name

V. WHAT TO DO WITH THIS FORM

Complete this Sworn Statement fully, sign it and return it to the person who asked you to complete it.

www.NFLConcussionSettlement.com
522453 Page 4 of 4 4/19/17
Appendix B

BAP Clinician’s Interpretation Guide

17 of 45
Retired NFL Football Players’ Baseline Assessment Program

Neuropsychologist Handbook
(the Clinician’s Interpretation Guide)

1. Introduction

The Baseline Assessment Program (BAP) includes a battery of standard neuropsychological tests
and clinical rating instruments designed to provide a standardized evaluation of the level of
cognitive functioning in retired professional football players. While the tests that are required
in this battery are fixed by the settlement agreement under which this program is administered,
some flexibility is permitted for adding measures that might be helpful to each player clinically.
An important goal of this program is to provide players with information about their cognitive
status and, if needed, a basis for additional medical follow-up.

For those interested in a quick introduction to the battery, as it is administered, turn to Section
5.

In addition, Section 4 of the Baseline Neuropsychology Test Battery and Specific Impairment
Criteria for Retired NFL Football Players set forth in Exhibit A-2 of the Settlement Agreement
(the “Test Battery”) references a “user manual” to be provided to neuropsychologists setting
out the cutoff scores, criteria for identifying impairment in each cognitive domain, and
statistical normative data to support the impairment criteria, which are listed below in Section
5. For reference, we list below certain primary sources for the relevant test manuals.

Test Manual References

WAIS-IV
http://www.pearsonclinical.com/psychology/products/100000392/wechsler-adult-intelligence-
scalefourth-edition-wais-iv.html

Wechsler Memory Scale – IV


http://www.pearsonclinical.com/psychology/products/100000281/wechsler-memory-scale--
fourth-edition-wms-iv.html

MMPI-2-RF
http://www.pearsonclinical.com/psychology/products/100000631/minnesota-multiphasic-
personality-inventory-2-rf-mmpi-2-rf.html

TOMM
http://www.mhs.com/product.aspx?gr=cli&id=overview&prod=tomm

18 of 45
Advanced Clinical Solutions (TOPF & Word Choice Test)
http://www.pearsonclinical.com/psychology/products/100000616/advanced-clinical-solutions-
for-the-wais-iv-and-wms-iv-acs.html

Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery (BDAE Complex


Ideational Material, Trail Making, COWAT, Category Test)
http://www4.parinc.com/Products/Product.aspx?ProductID=RCNAAC

Boston Naming Test


https://www.pearsonclinical.com.au/products/view/525

MSVT
http://wordmemorytest.com/products/

VSVT
http://www4.parinc.com/Products/Product.aspx?ProductID=VSVT

Clinical Dementia Rating (CDR)


http://alzheimer.wustl.edu/cdr/cdr.htm

Mini International Neuropsychiatric Interview (MINI)


http://www.medical-outcomes.com/index/mini

2. Design Rationale of the BAP

The BAP was designed to assess the functional domains outlined in the Neurocognitive
Disorders section of the 5th Edition of the Diagnostic and Statistical Manual of the American
Psychiatric Association (DSM-5), with some modifications. The specific domains assessed in the
BAP include:

(1) Complex Attention and Processing Speed


(2) Learning and Memory
(3) Visual-Perceptual Processing
(4) Language
(5) Executive Functioning

The sixth domain from the Neurocognitive Disorders section of the DSM-5, Social Cognition, is
not included in the BAP given that objective measures of social cognition are less well-
developed than other neurocognitive measures, particularly with respect to means of assessing
performance validity. The battery does include two measures of psychiatric symptomatology to
assess social and emotional functioning more broadly.

In addition, the DSM-5 domain of Perceptual Motor functioning, which incorporates Visual-
Perceptual Processing here, typically includes a Visuomotor component - one that includes

19 of 45
measures of praxis. This domain has been modified to exclude Visuomotor measures, given the
expectation of high base rates of orthopedic injury and rheumatologic disease in former
players.

The battery also includes measures of performance validity, functional status, and – as noted –
psychiatric symptomatology. These additional measures are designed to (1) ensure validity of
the assessment of neurocognitive impairment, (2) validate their association to actual difficulties
in everyday behavior, and (3) characterize the contributions of psychiatric symptomatology to
the overall clinical picture. With regard to psychiatric symptoms, it is important to note that
the existence of a psychiatric disorder does not necessarily invalidate the assessment of
impairment.

3. Purpose of the BAP

The purpose of the BAP is to provide a standardized, quantitative assessment of retired players’
level of neurocognitive functioning. A critical consideration in the design of the battery was a
reliance on well-established, widely available measures that practitioners in North America,
would be familiar with and have access to. This enhances accessibility for players, particularly
those who might be more severely neurocognitively impaired, or physically disabled. In
addition, tests were selected based on the availability of demographically-adjusted normative
data for both Caucasians and African Americans.

The BAP provides only one baseline assessment examination for each retired player. As noted
in Section 2 of the Test Battery, however, subsequent examinations may be administered
outside the BAP by Qualified MAF Physicians (as potentially assisted by a neuropsychologist
certified by the American Board of Clinical Neuropsychology (ABCN), which is a member board
of the American Board of Professional Psychology (ABPP)). If such examination results in a
Qualifying Diagnosis, the retired player may seek compensation through the Settlement
program.

4. Qualified Assessors in the BAP

The test battery must be administered by a Qualified BAP Provider, namely a neuropsychologist
certified by the American Board of Clinical Neuropsychology (ABCN), which is a member board
of the American Board of Professional Psychology (ABPP), who is registered as a provider with
the BAP Administrator. As part of the BAP, a neurologist will also be making an assessment of
each retired player, so that this data may be incorporated in a complete medical evaluation.

20 of 45
5. The BAP Test Battery

This next section describes (I.) the tests needed to conduct the BAP battery, (II.) the structure of
the battery, and (III.) considerations for administration.

I. Tests and Materials Needed: The following is a checklist of the test materials you will
need to conduct the battery:

-Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV) kit


-Wechsler Memory Test, 4th Edition (WMS-IV) kit
-Advanced Clinical Systems (ACS) package (Test of Premorbid Functioning [TOPF]
Word Choice Test, TOPF demographic questionnaires, ACS scoring software)
- Trail Making Test (including Trails A as preliminary task to Trails B)
- Boston Naming Test
- Boston Diagnostic Aphasia Exam (BDAE) Complex Ideational Material subtest
- Controlled Oral Word Association Test (F-A-S and Animal Naming tasks)
- Booklet Category Test
- Test of Memory Malingering
- Medical Symptom Validity Test (MSVT) or Victoria Symptom Validity Test (VSVT)
- MINI International Psychiatric Interview
- Minnesota Multiphasic Personality Inventory, 2nd Revision, Restructured Form
(MMPI-2-RF)
- Clinical Dementia Rating Scale
- Revised Comprehensive Norms for an Extended Halstead-Reitan Battery
Computer (PC) for ACS scoring and administration of MSVT or VSVT

II. Structure of the Battery: The BAP assessment battery is designed to assess (a)
premorbid functioning, (b) the five neurocognitive domains derived from the DSM-5
Neurocognitive Disorder section, as described above, (c) performance validity, (d)
functional status, and (e) psychiatric complaints and disorders. These are measured as
follows:

Premorbid Functioning is assessed via the ACS Test of Premorbid Functioning (TOPF), including
the Word Reading Test, as well as the simple and complex demographic questionnaire. Three
estimates will be generated: (1) the estimate from the Word Reading Test alone, (2) the
estimate from the complex demographic formula, and (3) the estimate from the combination of
Word Reading and the simple or complex demographic formula. Consideration of each of the
three estimates can be guided by Chapter 5 of WAIS-IV, WMS-IV, and ACS: Advances Clinical
Interpretation (Holdnack, et al).

a. Five Neurocognitive Domains are assessed via subtests from the Wechsler Adult
Intelligence Scale, 4th Revision (WAIS-IV), the Wechsler Memory Scale, 4th Revision
(WMS-IV), and specific neuropsychological tasks, as follows:

21 of 45
Complex Attention and Processing Speed
 WAIS-IV Digit Span
 WAIS-IV Arithmetic
 WAIS-IV Letter-Number Sequencing
 WAIS-IV Coding
 WAIS-IV Symbol Search
 WAIS-IV Cancellation

Learning and Memory


 WMS-IV Logical Memory I
 WMS-IV Verbal Paired Associates I
 WMS-IV Visual Reproduction I
 WMS-IV Logical Memory II
 WMS-IV Verbal Paired Associates II
 WMS-IV Visual Reproduction II

Visual-Perceptual Processing
 WAIS-IV Block Design
 WAIS-IV Matrix Reasoning
 WAIS-IV Visual Puzzles

Language
 Boston Naming Test
 Controlled Oral Word Association, Category Fluency (Animal
Naming)
 Boston Diagnostic Aphasia Exam, Complex Ideational Material
subtest

Executive Functioning
 WAIS-IV Similarities
 Controlled Oral Word Association, Letter Fluency (F-A-S)
 Trail Making Test, Part B
 Booklet Category Test

b. Performance validity is assessed via both embedded and stand-alone measures, as well as
an overall application and review of the clinical criteria for assessing performance validity
and malingering as proposed by Slick et al. (Slick DJ, Sherman EM, Iverson GL, Clin
Neuropsychol, 1999; hereafter referred to as the “Slick Criteria”; full criteria are listed in
Appendix A). A final judgement by the clinician about the quality of the examinee’s
responses and the validity of the data collected will be required. Complete analysis of
performance validity includes the following:

22 of 45
Embedded Performance Validity Measures (using ACS Scoring)
 WAIS-IV Reliable Digit Span
 WMS-IV Logical Memory Recognition
 WMS-IV Verbal Paired Associates Recognition
 WMS-IV Visual Reproduction Recognition

Stand-Alone Performance Validity Measures


 ACS Word Choice Test
 Test of Memory Malingering (TOMM)
 Medical Symptom Validity Test (MSVT) or Victoria Symptom
Validity Test (VSVT) or Word Memory Test

Slick Criteria Checklist (paraphrased; full criteria listed in Appendix A)


 Suboptimal scores on embedded and stand-alone
performance validity measures
 Pattern of performance markedly discrepant from accepted
models of CNS dysfunction
 Discrepancy between test data and observed behavior
 Discrepancy between test data and reliable collateral reports
 Discrepancy between test data and documented background
or history
 Self-reported history discrepant with documented history
 Self-reported symptoms discrepant with known patterns of
brain abnormality
 Self-reported symptoms discrepant with behavioral
observations
 Self-reported symptoms discrepant with reliable collaterals’
descriptions of behavior

c. Functional status is assessed via three of the Clinical Dementia Rating (CDR) subscales—
Community Affairs, Home & Hobby, and Personal Care (listed below). While the CDR is
generally administered in clinical practice with all six subscales, pursuant to the Settlement
Agreement, only these three of the CDR subscales are used to characterize functional
impairment. The CDR Worksheet provides guidance for review of these three subclasses at
pages 4-6 and can be found here:
http://knightadrc.wustl.edu/cdr/PDFs/Translations/English%20United%20States.pdf. The
basis for evaluating the results of these three subscales should be qualitative, that is,
assessing whether the qualitative results of the three subscales as a whole are generally
consistent with the neurocognitive results of the test battery (i.e., a player’s Neurocognitive
Impairment Level). The selected CDR levels correspond with the levels of Neurocognitive

23 of 45
Impairment as follows: CDR Category 0.5 (Questionable) with Level 1 Neurocognitive
Impairment, CDR Category 1.0 (Mild) with Level 1.5 Neurocognitive Impairment, and CDR
Category 2.0 (Moderate) with Level 2 Neurocognitive Impairment).

Documentation (e.g., medical records, employment records) is necessary to establish any


functional impairment (CDR 1.0 or greater) consistent with, or greater than BAP Level 1.5
Neurocognitive Impairment. The sufficiency of the documentary evidence shall be
determined by the provider making the Qualifying Diagnosis. If such documentary evidence
does not exist or is not available, evidence of functional impairment consistent with, or
greater than BAP Level 1.5 Neurocognitive Impairment may be established for the player on
the basis of (a) evidence of cognitive decline from a previous level of performance, in
accordance with the testing protocol set forth in this Manual, in the executive function
cognitive domain or the learning and memory cognitive domain, and at least one other
cognitive domain; and (b) a third-party sworn affidavit from a person familiar with the
Retired NFL Football Player’s condition (other than the player or his family members)
corroborating the Retired NFL Football Player’s functional impairment. The sufficiency of
any corroborating affidavit shall be determined by the provider making the Qualifying
Diagnosis. Supporting materials should be provided at or within two weeks of the
completion of the player’s baseline assessment examination.

CDR Subscales for Assessing Functional Impairment:


 Community Affairs
 Home and Hobbies
 Personal Care

d. Psychiatric Symptomatology and Diagnoses are assessed via both a self-rated questionnaire
as well as a structured interview.

Psychiatric Assessment
 MMPI-2-RF
 MINI International Psychiatric Interview

III. Considerations for Administration: The BAP is based on standard assessment


instruments with established procedures for administration. Nonetheless, some specific
considerations for administration are emphasized.

A. Establishing Premorbid Ability Level: The ACS TOPF depends on both a specific task
(Word Reading) as well as demographic assessment. Special care should be taken to
verify, either with family members or reliable collateral informants, the information
collected about demographics, personal, and family history. As a general rule, when
available, objective sources of information should be examined and balanced
appropriately with additional information when considering information from collateral
informants.

24 of 45
B. Administration of WAIS-IV and WMS-IV Subtests: Subtests from these instruments will
be administered in standard fashion, according to their respective test manuals.

C. Additional Measures: There are a number of measures that may be included to improve
the overall characterization of each player. These include the WAIS-IV Vocabulary and
Information subtests, and WMS-IV Designs and Spatial Addition subtests. Including
these subtests will allow computation of standard Index and IQ scores that may be
helpful to providing players with more detailed information about their condition. Trail
Making Part A is not a required measure in the BAP for interpretive purposes, but must
be administered because the norms for Part B are based on presumed administration of
Part A just prior to Part B.

D. Administration of Specific Neuropsychological Measures: Administration of the Trail


Making Test, Letter and Category Fluency, Boston Naming Test, Boston Diagnostic
Aphasia Battery Complex Ideational Material subtest, and Booklet Category Test will be
administered in standard fashion, according to their respective test manuals.

E. Performance Validity Tests and the Slick Criteria: Score validity should be evaluated by
examining ACS performance validity measures, other stand-alone performance validity
tests, and the Slick Criteria. Scores for four embedded ACS performance validity
measures, to be extracted from WAIS-IV and WMS-IV raw data, and the ACS Word
Choice Test should be assessed according to the guidelines set forth in Assessing
Performance Validity with the ACS, Chapter 7, by James A. Holdnack, Scott Millis, Glenn
J. Larrabee and Grant L. Iverson. Based on the Traumatic Brain Injury comparison group
that is part of the ACS package, 2 of 5 test scores falling below either the 10th percentile
of the Clinical Sample Base Rates, or 3 of 5 test scores falling below the 15 th percentile
would indicate high likelihood of invalid performance. These scores will then be
evaluated against performance on the other stand-alone measures (e.g. Test of Memory
Malingering, Medical Symptom Validity Test, Victoria Symptom Validity Test).

Stand-alone performance validity tests will be administered and interpreted according


to their respective manuals. After reviewing the embedded and stand-alone
performance validity measures, the provider should confirm his or her conclusion by
referencing the qualitative descriptions provided in the Slick Criteria, to determine if
findings are inconsistent with known patterns of brain dysfunction, clinical observation,
collateral reports, history, and/or known patterns of test performance before judging
performance to be suboptimal.

Instructions for judging each component point of the Slick Criteria is provided in Exhibit
A, as well as an overall rating of the quality of the data collected.

F. Advice to Players Regarding Performance Validity Tests: Players should be encouraged


to give their best effort at all times in the completion of the neuropsychological tests .

25 of 45
G. Psychiatric Rating Scales: The psychiatric rating scales will be administered according to
their respective manuals. For the MMPI-2-RF, computerized administration is
acceptable, including online administration, provided that adequate measures are taken
to insure test security and integrity of administration. Online administration, like
standard paper-and-pencil administration should take place under supervision by the
assessing neuropsychologist.

26 of 45
6. Proposed Order of Administration

The BAP test battery is designed to be administered in approximately 3.5 - 4.0 hours, although
administration time will depend on level of player impairment as well as extent of any
psychiatric issues. The following test order is suggested as a guideline (one that avoids most
confounds of interspersed tasks), but is not required. Given the length of the test battery,
administering at least one break is recommended in order to minimize confounds from possible
fatigue or decreased stamina. Additional breaks may be administered as necessary and/or
appropriate. To the extent you deviate from the proposed order, the psychological testing
should nonetheless be administered at the end of the test battery.

TOMM Learning and Immediate Recall


TOPF (Test of Premorbid Functioning)
BDAE Complex Ideational Material
TOMM Delayed Recall 45 mins

Trail Making Parts A and B


Controlled Oral Word Association Tests (Letter and Category)
Boston Naming Test
ACS Word Choice Test 30 mins

WAIS-IV
Block Design Subtest
Similarities Subtest
Digit Span Subtest
Matrix Reasoning Subtest
Coding Subtest
Visual Puzzles Subtest 40 mins
(Optional WAIS-IV Vocabulary and Information subtests
for computation of full set of Index and IQ scores)

WMS-IV (Immediate Learning and Recall)


Logical Memory I Subtest
Visual Reproduction I Subtest
Verbal Paired Associates I Subtest 20 mins
(Optional WMS-IV Designs and Spatial Addition subtests
for computation of full set of Index scores)

WAIS-IV
Letter Number Sequencing Subtest
Cancellation Subtest 10 mins

WMS-IV (Delayed Recall and Recognition)

27 of 45
Logical Memory II Subtest (Recall and Recognition)
Visual Reproduction II Subtest (Recall and Recognition)
Verbal Paired Associates II Subtest (Recall and Recognition) 15 mins

MSVT (Medical Symptom Validity Test) or


VSVT (Victoria Symptom Validity Test) or Word Memory Test
Learning and Immediate Recall 5 mins

WAIS-IV
Arithmetic Subtest
Symbol Search Subtest 10 mins

MSVT or VSVT Delayed Recall 5 mins

Booklet Category Test 10-20 mins

MMPI-2 RF 35-50 mins

MINI International Psychiatric Interview 15-35 mins

7. Special Limitations on the Ability to Perform

Players may present with significant mental and physical limitations that impact their ability to
execute tasks as required under typical circumstances. These may include severe dementia,
orthopedic injury, paralysis, muteness, agitation, other psychiatric issues, and limited facility
with English language. As in standard clinical practice, we will rely on the experience and skill of
the highly qualified assessors administering this battery to characterize neurocognitive
functioning to the best of their ability; however special note of these limitations will be
required. Any emergent psychiatric or behavioral issues should likewise be handled according
to your usual standards of care.

28 of 45
8. Specific Methods for Characterizing Impairment and Criteria for Impairment

This next section outlines the steps for characterizing players’ Level of Impairment, according
to the settlement. These involve standard procedures for scoring and norming tests, as well
evaluating test scores against criteria for determining the Level of Impairment. In general,
procedures are as follows:

1. Administer and score all tests


2. Convert test scores to demographically-corrected T-scores via ACS software (use of
the full demographic correction is recommended) or Revised Comprehensive Norms
for an Extended Halstead-Reitan Battery
3. Determine the Estimated Level of Premorbid Functioning via ACS software and
classify estimated premorbid ability as Below Average, Average, or Above Average
4. Using the appropriate table in Section 9 (beginning on page 13), determine the
number of tests within each domain of functioning that fall below selected cutoffs.
5. Classify each domain based on Level of Impairment (None, 1.0, 1.5, 2.0).
6. Classify embedded and stand-alone performance validity test performance as
Optimal or Suboptimal for each test.
7. Complete Slick Criteria Checklist and classify performance validity overall as Optimal
or Suboptimal.
8. Classify level of functional impairment on the Clinical Dementia Rating (CDR)
subscales of Community Affairs, Home and Hobbies, and Personal Care.
9. Report MMPI-2-RF score elevations for Validity, Restructured and Higher Order
Scales, as well as other specific scales from other subsets (i.e., PSY-5) as needed to
characterize clinical condition.
10. Report all diagnostic criteria met for specific Psychiatric Disorders on the MINI.

As in all neuropsychological assessment, impairment across the BAP battery is determined not
only by the level of performance on each individual test, but also by the Estimated Level of
Premorbid Functioning. Based on the results of the Test of Premorbid Functioning (TOPF) and
demographic estimates, an individual player will be characterized as having Above Average
(estimated premorbid IQ of > 110), Average (90-109), or Below Average (< 89) estimated
premorbid ability. This classification will then determine the particular set of Impairment
Criteria that will be used to assess overall impairment level. The criteria for impairment at each
Estimated Level of Premorbid Functioning are detailed below.

As noted above, there are 5 relevant domains of neurocognitive functioning, with multiple tests
within each domain. These tests contribute 3, 4 or 6 demographically-adjusted test scores for
the determination of impairment level. For determination of impairment level, no other tests
may be considered.

The basic principle for defining impairment is an overall pattern of performance that is
approximately 1.5 standard deviations (for Level 1 Impairment), 1.7-1.8 standard deviations (for
Level 1.5 Impairment) or 2 standard deviations (for Level 2 Impairment) below the person’s

29 of 45
expected level of premorbid functioning. These roughly correspond to a level of functioning
consistent with Moderate Cognitive Impairment, Early Dementia, and Moderate Dementia,
respectively, as defined in the Settlement and further explained in the Notice set forth in
Exhibit A-5 of the Settlement Agreement at Page 8.

Given that there are multiple tests within each domain, it is necessary to have more than one
low test score in a domain to qualify as impaired in that domain. In addition, for overall
impairment to be classified at Level 1.0, 1.5 or 2.0, impairment at this level must be
demonstrated in 2 domains (similar to the criteria for Alzheimer’s disease in DSM-5) to meet
the full criteria. Lastly, to be classified at Level 1.0, 1.5, or 2.0, impairment at that level must
include at least one of the following domains: Complex Attention, Learning and Memory or
Executive Function. By agreement, these are thought to be the domains most likely related to
the effects of player’s past occupational exposure.

30 of 45
9. Impairment Criteria: Below Average, Average and Above Average

Impairment Criteria: Below Average Estimated Level of Premorbid Functioning

Complex Attention and Processing Speed (6 test scores)


1. Level 1 Impairment: 3 or more scores below a T score of 35
2. Level 1.5 Impairment: 4 or more scores below a T score of 35; or meet for Level 1 and 2
scores below a T score of 30
3. Level 2 Impairment: 3 or more scores below a T score of 30
Learning and Memory (6 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 35
2. Level 1.5 Impairment: 4 or more scores below a T score of 35; or meet for Level 1 and 2
scores below a T score of 30
3. Level 2 Impairment: 3 or more scores below a T score of 30
Visual-Perceptual (3 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 37
2. Level 1.5 Impairment: meet for Level 1 and 2 scores below a T score of 35
3. Level 2 Impairment: 3 or more scores below a T score of 35
Language (3 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 37
2. Level 1.5 Impairment: meet for Level 1 and 2 scores below a T score of 35
3. Level 2 Impairment: 3 or more scores below a T score of 35
Executive Function (4 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: 3 or more scores below a T score of 35; or meet for Level 1 and 1
score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30

31 of 45
Impairment Criteria: Average Estimated Level of Premorbid Functioning

Complex Attention and Processing Speed (6 test scores)


1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: 3 or more scores below a T score of 35; or meet for Level 1 and 1
score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30
Learning and Memory (6 test scores)
1. Level 1 Impairment: 3 or more scores below a T score of 35
2. Level 1.5 Impairment: 4 or more scores below a T score of 35; or meet for Level 1 and 1
score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30
Visual-Perceptual (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 37
2. Level 1.5 Impairment: 3 or more scores below a T score of 37; or meet for Level 1 and 1
score below a T score of 35
3. Level 2 Impairment: 2 or more scores below a T score of 35
Language (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 37
2. Level 1.5 Impairment: 3 or more scores below a T score of 37; or meet for Level 1 and 1
score below a T score of 35
3. Level 2 Impairment: 2 or more scores below a T score of 35
Executive Function (4 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: 3 or more scores below a T score of 35; or meet for Level 1 and 1
score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30

32 of 45
Impairment Criteria: Above Average Estimated Level of Premorbid Functioning (A3 – E3)

Complex Attention and Processing Speed (6 test scores)


1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: meet for Level 1 and 3 or more scores below a T score of 37
3. Level 2 Impairment: 3 or more scores below a T score of 35
Learning and Memory (6 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 35
2. Level 1.5 Impairment: meet for Level 1 and 3 or more scores below a T score of 37
3. Level 2 Impairment: 3 or more scores below a T score of 35
Visual-Perceptual (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 40
2. Level 1.5 Impairment: 3 scores below at T score of 40; or meet for Level 1 and 1 score
below a T score of 37
3. Level 2 Impairment: 2 or more scores below a T score of 37
Language (3 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 40
2. Level 1.5 Impairment: 3 scores below at T score of 40; or meet for Level 1 and 1 score
below a T score of 37
3. Level 2 Impairment: 2 or more scores below a T score of 37
Executive Function (4 test scores)
1. Level 1 Impairment: 2 or more scores below a T score of 37
2. Level 1.5 Impairment: meet for Level 1 and 3 or more scores below a T score of 37; or
meet for Level 1 and 1 score below a T score of 30
3. Level 2 Impairment: 2 or more scores below a T score of 30

33 of 45
10. Score Reporting

A summary score sheet is attached to this handbook, and is available in Excel format for use in
report writing.

11. Narrative Report Template

The following is a recommended outline for the narrative report of test performance. In
general, this template follows standard report-writing format, adapted to the structure of the
BAP test battery and the manner it will be reviewed for compensation decisions. Additions are
allowed, but reports will be more easily processed if these general guidelines are followed.

Recommended Sections:

a. History of Presenting Problem


b. Relevant Personal/Medical History
c. Relevant Family History
d. Behavioral Observations
e. Limitations of the Examinee (e.g., English as a second language)
f. Validity Test Summary (including checklist of Slick criteria and overall judgment
about validity of data)
g. Primary Test Results
i. Premorbid Intellectual Functioning
ii. Current General Intellectual Functioning (if computed)
iii. Complex Attention and Processing Speed
iv. Learning and Memory
v. Visual-Perceptual Processing
vi. Language
vii. Executive Functioning
h. Functional Status (CDR subscale ratings)
i. Summary of Psychiatric Rating Scales (MMPI2-RF; MINI Psychiatric Interview)
j. Summary and Conclusions (a specific diagnosis of Level 1.0, Level 1.5 or Level
2.0, if any, should be stated)
k. Table of Test Results (as above)

34 of 45
Appendix A: Criteria for Evaluating Performance Validity (“Slick Criteria”)

Source: Slick DJ, Sherman EM, Iverson GL. Diagnostic criteria for malingered neurocognitive
dysfunction: proposed standards for clinical practice and research. Clin Neuropsychol, 1999,
13(4): 545-61.

1. Suboptimal scores on performance validity embedded indicators or tests. The cutoffs for
each test should be applied based on empirical findings.

2. A pattern of neuropsychological test performance that is markedly discrepant from


currently accepted models of normal and abnormal central nervous system (CNS) function.
The discrepancy must be consistent with an attempt to exaggerate or fabricate
neuropsychological dysfunction (e.g., a patient performs in the severely impaired range on
verbal attention measures but in the average range on memory testing; a patient misses
items on recognition testing that were consistently provided on previous free recall trials, or
misses many easy items when significantly harder items from the same test are passed).

3. Discrepancy between test data and observed behavior. Performance on two or more
neuropsychological tests within a domain are discrepant with observed level of cognitive
function in a way that suggests exaggeration or fabrication of dysfunction (e.g., a well-
educated patient who presents with no significant visual-perceptual deficits or language
disturbance in conversational speech performs in the severely impaired range on verbal
fluency and confrontation naming tests).

4. Discrepancy between test data and reliable collateral reports. Performance on two or more
neuropsychological tests within a domain are discrepant with day-to-day level of cognitive
function described by at least one reliable collateral informant in a way that suggests
exaggeration or fabrication of dysfunction (e.g., a patient handles all family finances but is
unable to perform simple math problems in testing).

5. Discrepancy between test data and documented background history. Improbably poor
performance on two or more standardized tests of cognitive function within a specific
domain (e.g., memory) that is inconsistent with documented neurological or psychiatric
history.

6. Self-reported history is discrepant with documented history. Reported history is markedly


discrepant with documented medical or psychosocial history and suggests attempts to
exaggerate deficits.

7. Self-reported symptoms are discrepant with known patterns of brain functioning. Reported
or endorsed symptoms are improbable in number, pattern, or severity; or markedly
inconsistent with expectations for the type or severity of documented medical problems.

35 of 45
8. Self-reported symptoms are discrepant with behavioral observations. Reported symptoms
are markedly inconsistent with observed behavior (e.g., a patient complains of severe
episodic memory deficits yet has little difficulty remembering names, events, or
appointments; a patient complains of severe cognitive deficits yet has little difficulty driving
independently and arrives on time for an appointment in an unfamiliar area; a patient
complains of severely slowed mentation and concentration problems yet easily follows
complex conversation).

9. Self-reported symptoms are discrepant with information obtained from collateral


informants. Reported symptoms, history, or observed behavior is inconsistent with
information obtained from other informants judged to be adequately reliable. The
discrepancy must be consistent with an attempt to exaggerate deficits (e.g., a patient
reports severe memory impairment and/or behaves as if severely memory-impaired, but his
spouse reports that the patient has minimal memory dysfunction at home).

36 of 45
Appendix C

MAF Diagnosing Physician Certification Form

37 of 45
MAF DIAGNOSING PHYSICIAN CERTIFICATION FORM
(for Qualifying Diagnoses made by Qualified MAF Physicians)

This MAF Diagnosing Physician Certification Form is to be used only by a Qualified MAF Physician in connection
with the Class Action Settlement in In re: National Football League Players’ Concussion Injury Litigation for the
purpose of determining whether the patient has a Qualifying Diagnosis for compensation under the Settlement
Agreement. The Qualifying Diagnoses and required testing protocols are described in detail in the Qualified MAF
Physician Manual the Claims Administrator provided to you when you were approved as a Qualified MAF Physician.
Use this form to certify a Qualifying Diagnosis you made on or after January 7, 2017, as a Qualified MAF Physician.
If you made the diagnosis before January 7, 2017, do not use this form; use the Pre-Effective Date Diagnosing
Physician Certification Form instead. Also, if you are a Qualified BAP Provider certifying a diagnosis you made in
the Baseline Assessment Program, do not use this form; use the BAP Diagnosing Physician Certification Form
instead.
You must complete this form in its entirety, sign it under penalty of perjury, and provide it to the Claims Administrator
(and to the patient, if requested) along with copies of all supporting medical records that you created or received in
connection with the Qualifying Diagnosis. The Claims Administrator shall provide the form and records to the
patient, who must submit these materials as part of a claim for compensation under the Class Action Settlement.
The Claims Administrator will review the form and the supporting medical records. All claims also are subject to
audit. Any finding of fraudulent conduct by you will be subject to, without limitation, your referral to appropriate
regulatory and disciplinary boards and agencies and/or federal authorities, and your disqualification from serving in
any aspect of the Class Action Settlement.
You are required to preserve all supporting medical records that you created or received in connection with the
Qualifying Diagnosis for the greater of: (a) 10 years after the date of the examination resulting in the Qualifying
Diagnosis; or (b) the period of time required under applicable state and federal laws.
If you have any questions, call the Claims Administrator toll free at 1-855-887-3485 or visit the Settlement Website at
https://www.nflconcussionsettlement.com.

MAF Diagnosing Physician Certification Form (for Diagnoses made by Qualified MAF Physicians) Page 1 of 4
MAF DIAGNOSING PHYSICIAN CERTIFICATION FORM
(for Qualifying Diagnoses made by Qualified MAF Physicians)

I. PATIENT INFORMATION

Settlement Program ID
First M.I. Last Suffix
Name

Address 1

Address 2

City
Address

State/Province

Postal Code Country

Telephone | | | |-| | | |-| | | | |

| | |/| | |/| | | | |
Date of Birth (Month/Day/Year)

| | |/| | |/| | | | |
Date of Death (if applicable) (Month/Day/Year)

II. QUALIFIED MAF PHYSICIAN INFORMATION

National Provider Identifier (NPI)


First Middle Initial Last
Physician Name

Office/Practice Name

MAF Diagnosing Physician Certification Form (for Diagnoses made by Qualified MAF Physicians) Page 2 of 4
MAF DIAGNOSING PHYSICIAN CERTIFICATION FORM
(for Qualifying Diagnoses made by Qualified MAF Physicians)

III. LICENSED NEUROPSYCHOLOGIST (IF ANY)

Did a licensed neuropsychologist assist you in making the Qualifying Diagnosis?

YES NO

If you answered Yes, identify that neuropsychologist. The neuropsychologist must be certified by the American
Board of Professional Psychology (ABPP) or the American Board of Clinical Neuropsychology (ABCN), a member
board of the American Board of Professional Psychology, in the specialty of Clinical Neuropsychology.
First Middle Initial Last
Neuropsychologist
Name

Office/Practice Name

IV. QUALIFYING DIAGNOSIS

Identify the patient’s diagnosis and the date of such diagnosis. See your Qualified MAF Physician Manual for the
criteria for each diagnosis. The identification of a condition, including through a blood test, genetic test, imaging
technique, or otherwise, that has not yet resulted in actual cognitive impairment and/or actual neuromuscular
impairment in the patient is not a Qualifying Diagnosis.

Qualifying Diagnosis Date of Diagnosis


| | |/| | |/| | | | |
Level 1.5 Neurocognitive Impairment (Month/Day/Year)

| | |/| | |/| | | | |
Level 2 Neurocognitive Impairment* (Month/Day/Year)

| | |/| | |/| | | | |
Alzheimer’s Disease (Month/Day/Year)

| | |/| | |/| | | | |
Parkinson’s Disease (Month/Day/Year)

| | |/| | |/| | | | |
ALS (amyotrophic lateral sclerosis) (Month/Day/Year)

MAF Diagnosing Physician Certification Form (for Diagnoses made by Qualified MAF Physicians) Page 3 of 4
MAF DIAGNOSING PHYSICIAN CERTIFICATION FORM
(for Qualifying Diagnoses made by Qualified MAF Physicians)

* If you provided a diagnosis of Level 2 Neurocognitive Impairment, did you determine that certain testing was
medically unnecessary because of the severity of the patient’s dementia (see your Qualified MAF Physician
Manual)?

YES NO

If you answered Yes, provide the factual basis for that determination:

V. CERTIFICATION

By signing below, I declare under penalty of perjury, pursuant to 28 U.S.C. § 1746, that all information provided in
this form, and all related supporting medical records, are true and correct to the best of my knowledge, information
and belief.

I acknowledge that any finding of fraudulent conduct may subject me to, without limitation, referral to appropriate
regulatory and disciplinary boards and agencies and/or federal authorities, and disqualification from serving in any
aspect of the Class Action Settlement.
Signature of
Qualified MAF Date | | |/| | |/| | | | |
(Month/Day/Year)
Physician
First M.I. Last Suffix
Printed Name

MAF Diagnosing Physician Certification Form (for Diagnoses made by Qualified MAF Physicians) Page 4 of 4
Appendix D

Monetary Award Claim Package HIPAA Authorization Form

42 of 45
MONETARY AWARD CLAIM PACKAGE HIPAA AUTHORIZATION FORM

You must complete and sign this Form if you are a Retired NFL Football Player or the Representative Claimant
of a Retired NFL Football Player and want to apply for a Monetary Award. This Form authorizes the use and
disclosure of “Protected Health Information” as that term is defined in 45 C.F.R. § 160.103, relating to the
processing of your claim in the NFL Concussion Settlement Program. Protected Health Information includes, but is
not limited to, information regarding the Retired NFL Football Player’s medical care, treatment, physical or mental
condition, and medical expenses.

I. RETIRED NFL FOOTBALL PLAYER INFORMATION

Settlement Program ID | | | | | | | | | |
First M.I. Last Suffix

Player Name

Social Security Number, Taxpayer ID or | | | |-| | |-| | | | |


Foreign ID Number (if Retired NFL Football
or
Player is not a U.S. Citizen) of Retired NFL
Football Player (if known) | | | | | | | | | | | |

Date of Birth of Retired NFL Football Player | | |/| | |/| | | | |


(Month/Day/Year)

II. ENTITIES AUTHORIZED TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

By signing and submitting this Form, I authorize the use and disclosure of all Protected Health Information
regarding my (or the Retired NFL Football Player’s, if signed by a Representative Claimant) medical care,
treatment, physical or mental condition, and medical expenses relating to my claim in the In re: National Football
League Players’ Concussion Injury Litigation Settlement program, as follows: (1) by the Claims Administrator,
Special Masters, BAP Administrator, Lien Resolution Administrator, designated Qualified BAP Providers, Qualified
BAP Pharmacy Vendors, Qualified MAF Physicians, Appeals Advisory Panel members, Appeals Advisory Panel
Consultants, the Court, Class Counsel, Counsel for the NFL Parties and the NFL Parties (which, in turn, may share
the Protected Health Information with the NFL Parties’ insurers or reinsurers) for use and/or disclosure with one
another in the performance of their functions and duties pursuant to the Settlement Agreement; (2) by the Lien
Resolution Administrator for use and/or disclosure to the holders of any liens, claims, or rights of subrogation,
indemnity, reimbursement, conditional or other payments, or interests of any type, including all Governmental
Payors (such as the Medicare Program, any state Medicaid Program, the Department of Veterans Affairs, Tricare,
Indian Health Services, and their respective contractors), Medicare Part C or Part D Programs, private health care
providers, health plans, and health insurers, and any contractors or recovery agents of the foregoing persons and
entities (collectively, “Lienholders”), for the purpose of identifying and resolving any potential Liens in connection
with any Monetary Award that I may receive; and (3) by the Lienholders for disclosure to the Lien Resolution
Administrator and Claims Administrator for the purpose of identifying and resolving any potential Liens in
connection with any Monetary Award that I may receive.

Monetary Award Claim Package HIPAA Authorization Form Page 1 of 3


MONETARY AWARD CLAIM PACKAGE HIPAA AUTHORIZATION FORM

III. AUTHORIZATION

By signing below, I acknowledge and understand all of the following:

I have the right to revoke this authorization at any time. If I wish to revoke the authorization, I must do so in
writing and must provide my written revocation to the Claims Administrator. The written revocation must be
1.
signed and dated. The revocation will not apply to any disclosures that already have been made in reliance
on this authorization prior to the date upon which the Claims Administrator receives my written revocation.

My authorization of the disclosure of the subject Retired NFL Football Player’s Protected Health Information
is voluntary, which means I can refuse to sign this Form. I do not need to sign this Form to obtain health
2. treatment from any medical provider or to enroll in or be eligible for any health plan benefits. However, I
recognize that if I do not sign this Form and submit it to the Claims Administrator, my Claim Package will be
incomplete under the terms of the Settlement Agreement and will not be processed.

Any Protected Health Information or other information released to the Claims Administrator, Special Masters,
BAP Administrator, Lien Resolution Administrator, Qualified BAP Providers, Qualified BAP Pharmacy
Vendors, Qualified MAF Physicians, Appeals Advisory Panel members, Appeals Advisory Panel
Consultants, the Court, Class Counsel, Counsel for the NFL Parties and the NFL Parties (including the NFL
3.
Parties’ insurers or reinsurers) may be subject to re-disclosure by such person/entity, and may no longer be
protected by applicable federal and state privacy laws. Each of those persons and entities, however, is
permitted to use and disclose your information only in accordance with this Form, the Settlement Agreement,
a contract executed pursuant to the Settlement Agreement, orders of the Court, and/or applicable law.

My Protected Health Information may include information relating to sexually transmitted disease, acquired
4. immunodeficiency syndrome (“AIDS”), or human immunodeficiency virus (“HIV”), behavioral or mental health
services and treatment for alcohol and drug abuse.

This Form is valid from the date of my signature in Section IV until the date that the Claims Administrator
5.
performs the last act to process the claim for a Monetary Award that I submitted with this Form.

6. I have a right to receive and retain a copy of this Form.

Any photostatic copy of this Form shall have the same authority as the original, and may be substituted in its
7.
place.

IV. SIGNATURE

The Retired NFL Football Player or Representative Claimant of the Retired NFL Football Player named in Section I
must sign and date this Form below. By signing below, I declare under penalty of perjury, pursuant to 28
U.S.C. § 1746, that all information provided in this HIPAA Authorization Form is true and correct to the best
of my knowledge, information and belief.

Signature Date | | |/| | |/| | | | |


(Month/Day/Year)

First M.I. Last Suffix


Printed Name

If you are signing this Form as a Representative Claimant,


describe your relationship to the Retired NFL Football Player and
your authority to act on his behalf:

Monetary Award Claim Package HIPAA Authorization Form Page 2 of 3


MONETARY AWARD CLAIM PACKAGE HIPAA AUTHORIZATION FORM

V. HOW TO SUBMIT THIS FORM

You may submit this Form in one of two ways:


NFL Class Action Settlement
Claims Administrator
By U.S. Mail:
P.O. Box 25369
Richmond, VA 23260
NFL Class Action Settlement
c/o BrownGreer PLC
By Delivery:
250 Rocketts Way
Richmond, VA 23231

Monetary Award Claim Package HIPAA Authorization Form Page 3 of 3

You might also like