1Your Contact Information2Select Settlement Benefit Claim Form Number T.D. v. Mercy Health Settlement Class Member Claim FormCircuit Court of St. Louis County, Missouri, Case No. 20SL-CC05974 DEADLINE: THIS CLAIM FORM MUST BE SUBMITTED ONLINE OR POSTMARKED BY JUNE 10, 2024, AND MUST BE FULLY COMPLETED, BE SIGNED UNDER OATH, AND MEET ALL CONDITIONS OF THE SETTLEMENT AGREEMENT. YOUR FAILURE TO SUBMIT A TIMELY CLAIM FORM WILL RESULT IN YOU FORFEITING ANY PAYMENT FOR WHICH YOU MAY BE ELIGIBLE UNDER THE SETTLEMENT. Instructions: Please read carefully the Notice of Class Action Settlement (“Notice”), which is included with this Claim Form. If you were notified by Mercy in December 2020 that a certain Mercy employee improperly accessed your or your minor child’s protected health information and/or personally identifiable information (the “Incident”), then you may be entitled to monetary benefits from the Settlement. YOU MUST SUBMIT THIS CLAIM FORM IN ORDER TO RECEIVE A SETTLEMENT PAYMENT.This Claim Form must be submitted by June 10, 2024. If you prefer to print and mail your Claim Form, you can download the Claim Form HERE. Claimant ID* Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Phone Number*Please provide a phone number where you can be reached if further information is required. CLASS MEMBERSHIP Records indicate that you were notified by Mercy in December 2020 that a certain Mercy employee improperly accessed your or your minor child’s protected health information and/or personally identifiable information (the “Incident”). By signing and submitting this Claim Form, you acknowledge that you were notified by Mercy in December 2020 about the Incident, that you have received and reviewed the Notice of Class Action Settlement (the “Notice”), that you understand the terms and statements in the Notice, and that you submit this Claim Form under the terms of the Notice and the Settlement Agreement described in the Notice. SETTLEMENT BENEFITS As a Class Member, you are entitled to receive either: (1) a flat payment of up to $90; or (2) reimbursement of up to $300 for time and expense (but no more than $150 for time) that you actually and reasonably incurred to address concerns of identity theft because of Mercy’s notice to you in December 2020 about the Incident. You cannot choose both the Flat Payment and the Time and Expense Reimbursement. If you do so, you will be deemed to have chosen the Flat Payment. Settlement Benefit Options* Flat Payment. I choose to receive a flat payment of up to $90. Reimbursement for Time and Expense. The Settlement allows for reimbursement of up to 5 hours of time at $30 per hour that you expended as a result of addressing concerns of identity theft because of Mercy’s notice to you in December 2020 about the Incident.Attestation Hours of Time I attest, under penalties of perjury, that I expended the specified hours of time below as a result of addressing concerns of identity theft because of Mercy’s notice to me in December 2020 about the Incident I expended this many hours of timeSelect Number of Hours1 Hour2 Hours3 Hours4 Hours5 HoursYou must also provide a description of the time that you claim to have expended to allow for validation of your claim. Please provide that description here:The Settlement allows for reimbursement of up to $300 (less the amount claimed by you for time expended by you) in expenses that you incurred as a result of addressing concerns of identity theft because of Mercy’s notice to you in December 2020 about the Incident.Attestation Expenses I attest, under penalties of perjury, that I incurred the specified expenses below as a result of addressing concerns of identity theft because of Mercy’s notice to me in December 2020 about the Incident. I incurred this amount of expensesPlease enter a number from 0 to 300.You must also provide a description of these expenses and documentation of these expenses. Please provide that description here and include that documentation with this Claim Form:Supporting Documentation Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 16 MB, Max. files: 5. Please note that if the amount of the valid and approved claims exceeds the amount of the Net Settlement Fund, all such valid and approved claims will be reduced on a pro rata basis before payment. The Claims Administrator may audit any and all claims and may require the submission of supplemental information reasonably required to evaluate any claims. Persons making false claims may be subject to civil or criminal penalties.Signature* I hereby agree to participate in the Settlement entered in the Civil Action and approved by the Court. I also consent and agree to be bound by any adjudication of the Civil Action by the Court. By signing below, I fully and finally discharge and release any and all of the Released Claims against Mercy and the Mercy Released Parties. I agree to be bound by this settlement and not to sue or otherwise make a claim against any of the Mercy Released Parties as to any of the Released Claims. I declare under penalty of perjury that the foregoing is true and correct. Printed Name*
