If you received a personalized notice in the mail with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. ABC12345678).

The deadline for submitting this proof of claim form is

If you were notified that your private information (“Personal Information”) could have been accessed in either or both Security Incidents in which certain of LifeBridge Health, Inc.’s (“LifeBridge’s”) affiliated computer network systems were the target of an external criminal-cyberattack that began as early as September 27, 2016, or in which an unauthorized user fraudulently obtained access to copies of documents held by M&T Bank in its lockbox account for LifeBridge’s affiliate, Sinai Hospital of Baltimore, Inc., between December 17, 2019, and April 30, 2020, you are a “Class Member.” If you received a Notice about this class action Settlement that is addressed to you, then the Settlement Administrator has already determined that you are a Class Member.

As a Class Member, you may be eligible to receive up to $250 total for ordinary unreimbursed losses, including up to $60 in compensation for lost time incurred as a result of the Security Incidents (“Out-of-Pocket Losses”), and up to $5,000 cash payment for reimbursement of extraordinary, proven monetary losses that are reasonably and fairly traceable to the Security Incidents (“Extraordinary Losses”), and up to an additional $40 in compensation for lost time if you have documented Extraordinary Losses.

If you intend to make a claim for Out-of-Pocket Losses or Extraordinary Losses, you will need to submit supporting documentation.

If you are a Class Member whose information may have been compromised as a result of both of the Security Incidents, you may make a claim for reimbursement related to either Security Incident or both of them.

Please read this Claim Form carefully and answer all questions. Failure to provide required information could result in a denial of your claim.

Cash payment amounts may be reduced pro rata (proportionately) depending on how many people submit such claims. Complete information about the Settlement and its benefits are available here.

This Claim Form may be submitted electronically via the Settlement Website at www.LBHSettlement.com or completed and mailed to the address below. Please type or legibly print all requested information, in blue or black ink. Mail your completed Claim Form, including any supporting documentation, by U.S. mail to:

LifeBridge Class Action Settlement
c/o Settlement Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103
CLAIMANT INFORMATION

* Required Fields

PAYMENT SELECTION

You have successfully requested a payment. Click here if you would like to choose a different payment method.

REIMBURSEMENT FOR OUT-OF-POCKET LOSSES

You may seek reimbursement for up to $250 in Out-of-Pocket Losses you incurred as a result of the Security Incidents. Out-of-Pocket Losses 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, which are attributable to the Security Incident.

As part of your claim for Out-of-Pocket losses, you may also make a claim for up to three (3) hours of lost time, compensated at $20/hr. for a total of up to $60, for time spent dealing with the Security Incidents. If you have documented Extraordinary Losses, you may make a claim for an additional two (2) hours of lost time, for an additional total of up to $40.

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EXTRAORDINARY LOSSES

You may also seek reimbursement for up to $5,000 for proven Extraordinary Losses only if (i) the loss is an actual, documented, and unreimbursed (except from your insurer) monetary loss; (ii) fairly traceable to either of the Security Incidents; (iii) the loss occurred between September 27, 2016, and February 1, 2023; and (iv) the loss is not already covered by one or more of the normal reimbursement categories above (including the Out-of-Pocket Losses set forth above). Please provide an itemized list of any Extraordinary Losses below. If you need additional lines, you may submit additional pages containing this information with your claim:

Supporting Documentation

Accepted file types are: PDF, TIF, JPG, GIF, PNG, WORD, EXCEL. Other file types will be rejected.

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    ATTESTATION

    I affirm under the laws of the United States, including penalty of perjury, that the information I have supplied in this claim form and any copies of documents that I am sending to support my claim are true and correct to the best of my knowledge.

    I understand that I may be asked to provide more information by the Settlement Administrator before my claim is complete.

    Your Claim Form has been submitted successfully.

    Please print this page for your records.

    Your Claim Details
    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
    Last Name
    Street Address
    Street Address 2
    City
    State
    Zip Code
    Email Address
    Phone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@LBHSettlement.com

    Click here to edit your Claim.

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