PAYMENT ELIGIBILITY INFORMATION. Please review the notice and sections 2.3 through 2.8 of the Settlement Agreement (available at xxx.xxxxxx.xxx) for more information on who is eligible for a payment. Please provide as much information as you can to help us figure out if you are entitled to a settlement payment.
PAYMENT ELIGIBILITY INFORMATION. To prepare for this section of the Claim Form, please review the Settlement Notice and Sections 2.1 through 2.3 of the Settlement Agreement (available for download at [settlement website]) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed. To help us determine if you are entitled to a settlement payment, please provide as much information as reasonably possible.
PAYMENT ELIGIBILITY INFORMATION. Please review the Notice and sections 2.1 through 2.2 of the Settlement Agreement (available at [INSERT WEBSITE]) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed. Please provide as much information as you can to help us figure out if you are entitled to a Settlement payment. Please provide the information listed below: Check the box for each category of documented out-of-pocket expenses, fraudulent charges, or lost time that you incurred between March 7, 2023, and the Claims Deadline as a result of the Data Incident. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish).
PAYMENT ELIGIBILITY INFORMATION. Please review the notice and paragraph 39 of the Settlement Agreement (available at xxx.XXXXXXXXXXXXXX.xxx) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed. Check the box for each category of out-of-pocket expenses, fraudulent charges, or lost time that you incurred/experienced as a result of the Data Breach. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish).
PAYMENT ELIGIBILITY INFORMATION. Please review the notice and sections ## through ## of the Settlement Agreement (available at www.<<URL>>) for more information on who is eligible for a payment. Please provide as much information as you can to help us figure out if you are entitled to a settlement payment. Settlement Class Members who file a valid claim will be eligible to receive an equal share of the Net Settlement Fund from Froedtert regarding the Data Incident. Settlement Class Members will receive only one payment. I attest that I logged into a MyChart patient portal account through Froedtert’s website at least once between February 1, 2017 and May 23, 2022.
PAYMENT ELIGIBILITY INFORMATION. Please review the Notice and sections 2.1 through 2.2 of the Settlement Agreement (available at [INSERT WEBSITE]) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed. Please provide as much information as you can to help us figure out if you are entitled to a Settlement payment. Please provide the information listed below: Check the box for each category of documented out-of-pocket expenses, fraudulent charges, or lost time that you incurred as a result of the Data Incident. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish).
PAYMENT ELIGIBILITY INFORMATION. To prepare for this section of the Claim Form, please review the Settlement Notice and Sections of the Settlement Agreement (available for download at [settlement website]) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed. To help us determine if you are entitled to a settlement payment, please provide as much information as reasonably possible. {9528441:2 } Questions? Call [toll-free number] or visit [settlement website] 1
A. Verification of Class Membership
(1) If you received notice of the settlement by postcard, in the boxes provided below, please provide the unique Claim ID from that notice: CLAIM ID [CLAIMS ADMINISTRATOR TO INSERT BOXES TO CONFORM TO NUMBER OF DIGITS IN CLAIM ID]
(2) If you did not receive a postcard notifying you of the Settlement, please provide the name you used at the time you received treatment from Beaumont, the year or years in which you received treatment at Beaumont, and check the box next to the location of the facility at which you received treatment from Beaumont. NAME [CLAIMS ADMINISTRATOR TO ADD BOXES] ocument Submitted for Filing to MI Oakland County 6th Circuit Court. YEAR(S) OF TREATMENT [CLAIMS ADMINISTRATOR TO ADD BOXES]
PAYMENT ELIGIBILITY INFORMATION. Please review the notice and section 2.1 of the Settlement Agreement (available at www. .com) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed. Please provide as much information as you can to help us figure out if you are entitled to a settlement payment. Please provide the information listed below: Check the box for each category of your expenses that you had to pay as a result of the Data Incident. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may xxxx out any unrelated transactions if you wish).
