Fix A Claim | 21st Century Oncology Customer Data Security Breach Litigation

Deficiency Reasons

Please use the upload tool below to provide documentation to rebut the determination that:

CLAIM FORM FOR 21ST CENTURY ONCOLOGY DATA BREACH BENEFITS

YOU MAY USE THIS FORM TO MAKE A CLAIM FOR CREDIT MONITORING AND INSURANCE SERVICES AND/OR CASH PAYMENTS FOR REIMBURSEMENT OF FRAUD/OUT-OF-POCKET COSTS, DOCUMENTED TIME, AND/OR DEFAULT TIME

The DEADLINE to submit this Claim Form is: May 10, 2021

SECTION I - GENERAL INSTRUCTIONS

If you are one of the approximately 2,213,597 patients of 21st Century Oncology Investments, LLC or 21st Century Oncology of California, a Medical Corporation (together, “21st Century Oncology” or “Defendants”) who were notified in March 2016 about a data breach that occurred on or about October 3, 2015, where 21st Century Oncology patients’ personally identifiable information and/or protected health information, including names, Social Security numbers, physicians’ names, medical diagnoses, treatment information, and insurance information, may have been accessed by an unauthorized party (the “Data Breach”), you are a Settlement Class Member and entitled to participate in the Settlement. If you received a notice about this class action Settlement addressed to you, then the Settlement Administrator has already determined that you are a Settlement Class Member. If you are not sure whether you are a Settlement Class Member, you may email the Settlement Administrator at info@21COSettlement.com.

As a Settlement Class Member, you are eligible to receive two years of free Credit Monitoring and Identity Theft Insurance Services (“Credit Monitoring and Insurance Services”); a cash payment of up to $40 for up to 2 hours of time fairly traceable to the Data Breach valued at up to $20 per hour (“Default Time”); a cash payment of up to $260 for up to 13 hours of additional time spent fairly traceable to the Data Breach valued at up to $20 per hour (“Documented Timed”); and a cash payment of up to $10,000 for documented losses and/or expenditures fairly traceable to the Data Breach (“Fraud/Out-of-Pocket Costs”).

The free Credit Monitoring and Insurance Services offered is the Individual Total Plan provided by Identity Guard, valued at $16.67 per month. If you are already subscribed to the Individual Total Plan with Identity Guard, two additional years will be added to your current plan for free.

CASH PAYMENTS AMOUNTS MAY BE REDUCED PRO RATA (PROPORTIONATELY) DEPENDING ON HOW MANY PEOPLE SUBMIT SUCH CLAIMS. Additional payments may also be sent if the settlement amount is not exhausted. Complete information about the Settlement and its benefits are available on the Notice and the Settlement Agreement.

This Claim Form may be submitted by May 10, 2021.

SECTION II - CLAIMANT INFORMATION

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 and Credit Monitoring and Insurance Services, you must notify the Settlement Administrator in writing at the address above.

First Name *

Middle Initial

Last Name *

Alternative Name(s)

Street 1 *

Street 2

City *

State *

Zip Code *

Telephone Number (Primary)

Telephone Number (Secondary)

Email Address *

Date of Birth (MM/DD/YYYY) *

* Denotes required fields.

SECTION III - CREDIT MONITORING AND INSURANCE SERVICES

If you wish to receive Credit Monitoring and Insurance Services, you must provide your email address in the space provided below. Submitting this Claim Form will not automatically enroll you into Credit Monitoring and Insurance Services. To enroll, you must follow the instructions sent to your email address, below, after the Settlement is approved and becomes final.

Email Address to Credit Monitoring and Insurance Services

SECTION IV - DEFAULT TIME PAYMENT

If you wish to receive a Default Time Payment, simply fill out Section II, above, and submit this Claim Form. A check will be mailed to the address you provided, as long as the Net Settlement Fund is not depleted by the claims for Fraud/Out-of-Pocket Costs.

If you would prefer to receive your Settlement Payment via PayPal, please provide the email address associated with your PayPal account below [OPTIONAL]:

PayPal Email Address

SECTION V - DOCUMENTED TIME PAYMENT

In addition to Credit Monitoring and Insurance Services, a Default Time Payment, and reimbursement of Fraud/Out-of-Pocket Costs, you may file a claim for a payment for Documented Time for $20 per hour for up to thirteen hours of additional time you spent remedying or attempting to remedy issues fairly traceable to the Data Breach, including, for example: time spent on any identity theft or fraud, bank fees, card cancellations, credit card fees, late fees, declined payment fees, overdraft fees, returned check fees, customer service fees, card cancellation or replacement fees, credit-related costs related to purchasing credit reports, credit monitoring or identity theft protection, placing a freeze or alert on credit reports, and replacing a driver’s license, state identification card, or Social Security number.

To make a claim for Documented Time: (i) state, in the space provided below, the number of additional hours (up to thirteen) you spent addressing or remedying issues caused by the Data Breach; (ii) sign the attestation at the end of this Claim Form; and (iii) submit Reasonable Documentation supporting your claimed time. Documented Time will be deemed fairly traceable to the Data Breach by the Settlement Administrator if the Documented Time occurred on or after October 3, 2015, and the Settlement Administrator determines the Documented Time incurred are fairly traceable to the type of information disclosed in the Data Breach.

Number of additional hours spent remedying issues fairly traceable to the Data Breach (up to 13):

If you do not submit Reasonable Documentation supporting a Documented Time Payment claim, or your claim for Documented Time is rejected by the Settlement Administrator for any reason and you do not cure the defect, you may still receive a Default Time Payment.

SECTION VI - REIMBURSEMENT FOR FRAUD/OUT-OF-POCKET COSTS

In addition to Credit Monitoring and Insurance Services and a Default Time Payment, you may also seek reimbursement for up to $10,000 of Fraud/Out-of-Pocket Costs you incurred that are fairly traceable to the Data Breach. Fraud/Out-of-Pocket Costs include, for example: late fees, declined payment fees, overdraft fees, returned check fees, customer service fees, card cancellation or replacement fees, credit-related costs related to purchasing credit reports, credit monitoring or identity theft protection, costs to place a freeze or alert on credit reports, costs to replace a driver’s license, state identification card, or social security number, or losses incurred as a result of documented identity theft or fraud, which are attributable to the Data Breach at issue in this Action.

In order to make a claim for Fraud/Out-of-Pocket Costs you must (i) fill out the information below and/or on a separate sheet submitted with this Claim Form; (ii) sign the attestation at the end of this Claim Form (section VII); and (iii) include Reasonable Documentation supporting each claimed cost along with this Claim Form. Fraud/Out-of-Pocket Costs will be deemed fairly traceable to the Data Breach by the Settlement Administrator if the Fraud/Out-of-Pocket Costs occurred on or after October 3, 2015 and the Settlement Administrator determines the Fraud/Out-of-Pocket Costs are fairly traceable to the information disclosed in the Data Breach.

Cost Type (Check all that apply)	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation (What you are attaching and why)
Cost Type (Check all that apply) Losses from identity theft or fraud	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Examples: Receipt for hiring service to assist you in addressing identity theft; Accountant bill for re-filing tax return.
Cost Type (Check all that apply) Fees or costs incurred in connection with identity theft or fraud	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Examples: Receipt for hiring service to assist you in addressing identity theft; Accountant bill for re-filing tax return.
Cost Type (Check all that apply) Lost interest or other damages resulting from delayed state and/or federal tax refund resulting from fraudulent tax return	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Examples: Letter from IRS or state taxing authority about tax fraud in your name; Documents reflecting length of time you waited to receive your tax refund and the amount thereof.
Cost Type (Check all that apply) Credit freeze	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Examples: Notices or account statements reflecting payment for a credit freeze.
Cost Type (Check all that apply) Credit monitoring that was purchased after October 3, 2015 through the date on which the Credit Monitoring and Insurance Services became available through the Settlement	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Examples: Receipts or account statements reflecting purchases made for identity theft protection and/or credit monitoring services.
Cost Type (Check all that apply) Miscellaneous expenses such as notary, fax, postage, copying, mileage, and/or long-distance telephone charges	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Example: Phone bills, gas receipts, postage receipts; detailed list of locations to which you traveled (such as police station or IRS office), indication of why you traveled there (i.e. police report or letter from IRS regarding falsified tax return) and number of miles you traveled.
Cost Type (Check all that apply) Other (provide detailed description)	Date of Loss (Approximate)	Amount of Loss	Description of Reasonable Documentation Please provide detailed description below or in a separate document submitted with this Claim Form.

DOCUMENTS

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SECTION VIII- ATTESTATION
(REQUIRED FOR FRAUD/OUT-OF-POCKET COSTS AND/OR DOCUMENTED TIME CLAIMS)

I, [Name] , declare that I expended the Documented Time and/or incurred the Fraud/Out-of-Pocket Costs claimed above as a result of the Data Breach.

I declare under penalty of perjury under the laws of Florida and of the United States of America that the foregoing is true and correct.

Signature *

Date

In Re: 21st Century Oncology Customer Data Security Breach Litigation

Case No. 8:16-md-2737-MSS-AEP

United States District Court for the Middle District of Florida

CLAIM FORM FOR 21ST CENTURY ONCOLOGY DATA BREACH BENEFITS

Your Deficiency Response has been submitted successfully.

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
Middle Initial
Last Name
Street 1
Street 2
City
State
Zip Code
Telephone Number (Primary)
Telephone Number (Secondary)
Email Address