Online Claim Form

If you are a current or former member of the Kaiser Foundation Health Plan, Inc. or any of its affiliates in California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington, or the District of Columbia, and accessed the authenticated pages of the Kaiser Permanente websites or mobile applications listed below from November 2017 to May 2024, you are a Settlement Class Member and may submit a Claim Form in order to receive a payment from the Settlement created in John Doe, et al. v. Kaiser Foundation Health Plan, Inc., et al., Case No. 3:23-cv-02865-EMC (N.D. Cal.) (“Action”):

TO RECEIVE A PAYMENT FROM THE SETTLEMENT, YOU MUST SUBMIT A CLAIM FORM ONLINE BELOW, OR YOU CAN COMPLETE AND MAIL THIS CLAIM FORM TO THE SETTLEMENT ADMINISTRATION AT THE MAILING ADDRESS BELOW, POSTMARKED NO LATER THAN MARCH 12, 2026.

Kaiser Privacy Breach Settlement

c/o Strategic Claims Services, Inc.

P.O. Box 230

600 N. Jackson Street, Suite 205

Media, PA 19063

FAILURE TO SUBMIT YOUR CLAIM FORM BY MARCH 12, 2026 MAY PRECLUDE YOU FROM RECEIVING ANY MONEY IN CONNECTION WITH THE SETTLEMENT. IF YOU ARE A SETTLEMENT CLASS MEMBER AND DO NOT SUBMIT A VALID CLAIM FORM, YOU WILL NOT SHARE IN THE SETTLEMENT BUT YOU NEVERTHELESS WILL BE BOUND BY THE SETTLEMENT (INCLUDING ITS RELEASE OF CLAIMS) AND ALL OF THE ORDERS AND JUDGMENTS ENTERED BY THE COURT IN THE ACTION.

All questions regarding this Claim Form and your eligibility to receive a payment from the Settlement should be directed to the Settlement Administrator at:

Email: info@KaiserPrivacySettlement.com or Telephone: 1-855-783-3816

1. I submit this Claim Form under the terms of the Amended Stipulation of Settlement dated  December 1, 2025, (“Stipulation”) described in the Notice of Pendency and Proposed Settlement of Class Action and Fairness Hearing (“Notice”) available at www.KaiserPrivacySettlement.com. I also submit to the jurisdiction of the United States District Court for the Northern District of California with respect to my claim as a Settlement Class Member and for purposes of enforcing the releases and covenant not to sue set forth in the Stipulation. I further acknowledge that I am bound by and subject to the terms of any judgment that may be entered in this Action. I have not submitted any other claim covering the same allegations and know of no other Person having done so on my behalf.  
   • I certify that I have read and understand the contents of the Notice and this Claim Form, including the releases provided for in the Stipulation and the terms of the Plan of Allocation.

    

   • I certify that I am a member of the Settlement Class, as defined in the Stipulation and the Notice, and am not excluded by definition from the Settlement Class as follows:

   Excluded from the Settlement Class are (1) the Judges presiding over the Action, Class Counsel, Sutter Counsel, and immediate members of their families; (2) Kaiser Foundation Health Plan, Inc., its subsidiaries, parent companies, successors, predecessors, and any entity in which the Kaiser Foundation Health Plan, Inc. or its parent has a controlling interest, and its current or former officers and directors; (3) Persons who properly execute and submit a request for exclusions prior to the Opt-Out Deadline; (4) the successors or assigns of any such excluded Persons; and (5) Kaiser Permanente Members Who Have Chosen to Arbitrate, with “Members Who Have Chosen to Arbitrate” defined as (i) the seventeen (17) current and former Kaiser Permanente members identified in Appendix A to the Stipulation of Settlement represented by one or more of the Potter Handy, LLP (“Potter Handy”), Milberg Coleman Bryson Phillips Grossman, LLC (“Milberg”), and Bryson Harris Suciu & DeMay, PLLC (“Bryson”) law firms; and (ii) the four (4) current and former Kaiser Permanente members identified in Appendix B to the Stipulation of Settlement represented by the Shay Legal, APC and Swigart Law Group, APC law firms. Or, if I am among the twenty-one (21) Members Who Have Chosen to Arbitrate, I certify that I have withdrawn and/or dismissed my arbitration on or before January 19, 2026.

   • I certify that I have not submitted or intend to submit a request for exclusion from the Settlement Class.

    

   • I certify that I am NOT subject to backup withholding under the provisions of Section 3406 (a)(1)(c) of the Internal Revenue Code because: (a) I am exempt from backup withholding; or (b) I have not been notified by the I.R.S. that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (c) the I.R.S. has notified me that I am no longer subject to backup withholding.

   NOTE: If you have been notified by the I.R.S. that you are subject to backup withholding, please strike out the language that you are not subject to backup withholding in the certification above.

   • I agree to waive my right to trial by jury, to the extent it exists, and agree to the determination by the Court of the validity or amount of this Claim, and waive any right of appeal or review with respect to such determination.