Tampa General Hospital Class Action Settlement
c/o Dahl Administration
PO Box 3613
Minneapolis, MN 55403-0613
IN THE THIRTEENTH JUDICIAL CIRCUIT COURT
HILLSBOROUGH COUNTY, FLORIDA
John Doe v. Florida Health Sciences Center, Inc.
Case No. 14-CA-012657
REIMBURSEMENT CLAIM FORM
Settlement Class Members are entitled to recover reimbursement of actual documented and unreimbursed losses as a result of the
fraudulent use of the Settlement Class Member’s protected health information or personally identifying information (a “Stolen Identity
Event”). Additional information is contained in the Notice of Pendency of Class Action, available at www.TampaHospitalSettlement.com
or by calling 1-888-755-9508.
If you have questions, call 1-888-755-9508 or send an email to: [email protected]. To receive reimbursement of your
actual losses, you must: (1) fill out this form completely, (2) attach the required supporting documentation, and (3) submit this form and
the supporting documentation to the address above. The deadline to submit a claim is April 24, 2017.
CLASS MEMBER & CLAIMANT INFORMATION
Class Member First Name
MI
Class Member Last Name
Mailing Address (Street, PO Box, Suite or Office Number, as applicable)
City
Telephone Number (including Area Code)
-
State
Zip Code
Email Address
Please state the name and address of any person or entity from which you received notice of the Stolen Identity Event:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please describe the Stolen Identity Event in reasonable detail:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please state the amount of your actual losses from the Stolen Identity Event, and describe them in reasonable detail:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
I am attaching the following documentation:
(1) Any written report by a third party regarding the Stolen Identity Event;
(2) Any documentation from a third party of your actual losses resulting from the Stolen Identity Event; and
(3) Any documentation from a third party that your actual losses will not be mitigated, such as by writing off charges or
reimbursing you for the actual losses.
SIGNATURE & CERTIFICATION UNDER PENALTY OF PERJURY
I hereby declare under the penalty of perjury that I believe that the information I am providing in support of my claim is true and correct. I further
certify that any official documentation that I have submitted in support of my claim consists of unaltered documents in my possession.
Signature
Date
MM/DD/YY
Mail your claim to:
Tampa General Hospital Class Action Settlement
c/o Dahl Administration
PO Box 3613
Minneapolis, MN 55403-0613