Online Opt-Out Form | Kaiser Privacy Breach Settlement

Kaiser Privacy Breach Opt-Out Form

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Kaiser Privacy Breach Opt-Out Form

If you would like to exclude yourself from the Settlement Class, please fill out the form on this page. A printable version can also be found HERE

If you are a law firm acting on behalf of your clients please contact the Settlement Administrator at exclusions@kaiserprivacysettlement.com for a way to send us information in bulk form.

By signing and submitting this Opt-Out Form, I am stating to the Court that I DO NOT want to be part of the Settlement Class. I also understand that: (1) I will not be eligible to receive any Settlement benefits; (2) I cannot object to the Settlement; (3) I will not be legally bound by anything that happens in this lawsuit; and (4) I may be able to pursue (or continue to pursue) a claim against Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and the Kaiser Foundation Plan of Washington (“Kaiser”) or any of the Released Parties in the future.

Settlement Class Member Unique ID(Required)

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IDFound

Settlement Class Member Name(Required)

First Last

Email Associated with your Kaiser Account(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I understand that by signing and submitting this Opt-Out Form, I am stating to the Court that I DO NOT want to be part of the Settlement Class. I also understand that: (1) I will not be eligible to receive any Settlement benefits; (2) I cannot object to the Settlement; (3) I will not be legally bound by anything that happens in this lawsuit; and (4) I may be able to pursue (or continue to pursue) a claim against Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and the Kaiser Foundation Plan of Washington (“Kaiser”) or any of the Released Parties in the future.

I affirm under the laws of the United States that the information I have supplied is true and correct to the best of my knowledge and attest that: (1) I am a past and/or current member of Kaiser; and (2) the following is my personally-signed signature.

Signature(Required)

Date(Required)

Name(Required)

If you are submitting this form on behalf of a person under your legal guardianship (such as a minor child). Print their name below.

Name Signed on Behalf of

Unique ID