If you received a personalized notice in the mail or via email 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. 12345678).

If you did not receive a personalized Notice in the mail or via email, click below to complete a Claim Form.

Please select which claim form you would like to submit.

USE THIS FORM ONLY IF YOU ARE A MEMBER OF THE SETTLEMENT SUBCLASS TO MAKE A CLAIM FOR IDENTITY THEFT PROTECTION AND CREDIT MONITORING SERVICES AND/OR COMPENSATION FOR UNREIMBURSED LOSSES

If your personally identifiable information or protected health information was compromised as a result of the cyberattack that San Juan Regional Medical Center learned of or about September 8, 2020 (the “Cyberattack”), you are a Settlement Class Member and are eligible to complete this Claim Form to request two (2) years of Identity Defense Complete identity protection and credit monitoring service free of charge.

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

This Claim Form may be submitted electronically 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:

SJRM Claims Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103

If you were notified by San Juan Regional Medical Center (“SJRMC”) that your Social Security, financial account, driver’s license, or passport numbers were potentially compromised as a result of the cyberattack that SJRMC learned of on or about September 8, 2020 (“Cyberattack”), you are a member of the Settlement Subclass and are eligible to complete this Claim Form to request two (2) years of Identity Defense Complete identity protection and credit monitoring service free of charge and/or compensation for unreimbursed losses, up to a total of $2,500 (“Unreimbursed Losses”).

Unreimbursed Losses include the following:

  1. Out-of-pocket expenses incurred as a result of the Cyberattack, including bank fees, long distance phone charges, cell phone charges (only if charged by the minute), data charges (only if charged based on the amount of data used), postage, or gasoline for local travel;
  2. Fees for credit reports, credit monitoring, or other identity theft insurance product purchased on or after the date on which the Settlement Subclass Member received written notice of the Cyberattack through October 13, 2022;
  3. Compensation for proven monetary loss, professional fees including attorneys’ fees, accountants’ fees, and fees for credit repair services incurred as a result of the Cyberattack; and
  4. Up to 3 hours of lost time at a rate of $17.50 per hour if at least one full hour was spent dealing with the Cyberattack.

Compensation for the above losses (except lost time) will only be paid if:

  • The loss is an actual, documented, and unreimbursed monetary loss;
  • The loss was more likely than not caused by the Cyberattack;
  • The loss occurred between September 7, 2020 and February 8, 2023;
  • You made reasonable efforts to avoid, or seek reimbursement for, the loss, including but not limited to exhaustion of all available credit monitoring insurance and identity theft insurance; and
  • Documentation of the claimed losses is not “self-prepared.” Self-prepared documents, such as handwritten receipts, are, by themselves, insufficient to receive reimbursement.

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

This Claim Form may be submitted electronically 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:

SJRM Claims Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103

I. CLASS MEMBER NAME AND CONTACT INFORMATION

Provide your name and contact information below. You must notify the Claims Administrator if your contact information changes after you submit this form.

* Required Fields

II. PROOF OF CLASS MEMBERSHIP

Enter the Notice ID Number provided on your Notice:

If you lost your Notice ID Number or otherwise have reason to believe you may be a member of the subclass, please contact the settlement administrator at info@HendersonDataBreachSettlement.com.

Enter the approximate timeframe in which you were a patient or employee of SJRMC:

III. IDENTITY THEFT PROTECTION
IV. UNREIMBURSED LOSSES

All members of the Settlement Subclass who submit a Valid Claim using this Claim Form are eligible for reimbursement of the following documented out-of-pocket expenses, not to exceed $2,500 per member of the Settlement Subclass, that were incurred as a result of the Cyberattack:

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss
Examples of Supporting Documentation: Phone bills, gas receipts, postage receipts; detailed list of locations to which you traveled (i.e., police station, IRS office), indication of why you traveled there (i.e., police report or letter from IRS re: falsified tax return) and number of miles you traveled.
Examples of Supporting Documentation: Receipts or account statements reflecting purchases made for Credit Monitoring or Identity Theft Insurance Services.
Examples of Supporting Documentation: Invoices or statements reflecting payments made for professional fees/services.
V. UPLOAD SUPPORTING DOCUMENTATION

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

Please confirm in the grid below that your file has been successfully uploaded.

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    VI. COMPENSATION FOR LOST TIME

    All members of the Settlement Subclass who have spent time dealing with the Cyberattack may claim up to three (3) hours for lost time at a rate of $17.50 per hour. Any payment for lost time is included in the $2,500 cap per Settlement Subclass member (no documentation is required).

    VII. PAYMENT SELECTION

    Please select one of the following payment options, which will be used should you be eligible to receive a settlement payment:

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

    VIII. ATTESTATION & SIGNATURE

    I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below.

    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
    City
    State
    Province
    Zip Code
    Postal Code
    Country
    Email Address
    Telephone Number
    Signature
    Date

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

    Click here to edit your Claim.

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