Submit a Claim

Claim Form

Contact Information

Please provide contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form.

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone

Medical Identity Protection

All Class Members are eligible to enroll in two (2) years of CyEx Medical Shield Total with three-bureau monitoring. This comprehensive service comes with $1 million of medical identity theft insurance, and includes monitoring for:

healthcare insurance ID exposure
Medical Record Number (MRN) exposure
unauthorized Health Savings Account (HSA) spending

If anything suspicious happens, you will be able to talk to a fraud resolution agent to help fix any problems.

Would you like to enroll in two (2) years of CyEx Medical Shield Total?*

YesNo

Note: If you elect medical identity protection, you will need to follow instructions and use an "activation code" that you receive after the Settlement is final. Identity theft services will not begin until you use your activation code to enroll. Activation instructions will be sent to the email address you provided in the Contact Information section above.

Cash Payment

All Class Members may claim one of the following payments options.

Documented Losses. If you incurred actual, documented out-of-pocket losses due to the Data Breach, you can get back up to $5,000.00.
Alternative Cash Payment. You may claim a one-time cash payment, estimated at $85.00.

Please select your Cash Payment.*

I would like to claim for Documented Losses.I would like to claim for the Alternative Cash Payment.I do not wish to claim for a Cash Payment option.

Attestation & Signature

By submitting this Claim Form, I swear and affirm on penalty of perjury that the information provided in this Claim Form, and any supporting documentation, is true and correct to the best of my knowledge.

I understand that my claim is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim is considered complete and valid.

Signature

Date