TO FILE AN OPT-OUT, THIS FORM MUST BE SUBMITTED BY

Class Member Information
Signature

I wish to be excluded from the Settlement Class in Johnson, et al. v. LifeBridge Health, Inc., Case No. 24-C-18-006801. I understand that by submitting this form I am requesting exclusion from the Settlement, and I will not receive any benefits from this Settlement.

*Required Fields

Your Request has been submitted successfully.

You will receive an email confirmation with the information below.
You may also print this page for your records.

Your Opt Out Request Details

First Name
Last Name
Street Address
City
State
Zip Code
Telephone Number
Email Address
Claim Number
Signature
Date

If you have any questions regarding your Opt Out Request, please email us at Info@LBHSettlement.com.