ECL Privacy Breach Litigation - Physician Claim Form

Physician Claim Form - Page 1

Unique ID:

Please provide the Unique ID provided in the Postcard Notice that you received.*

The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of cash payments, you must notify the Settlement Administrator in writing at the address found on the Contact page here.

Practice Name:*

Physician Licensee Name:*

Country:*

Address Line 1:*

Address Line 2:

Address Line 3:

Address Line 4:

Address Line 5:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:

Email Address:*

Please Note: The email address provided above will be used for all communication regarding your claim.

Physician Claim Form - Page 1

Unique ID:

Contact Information: