Submit a Claim - Instructions

If you are a current or former patient at UCLA Health, you may be able to receive benefits from this settlement. You are eligible to do the following:

  • Submit an ID Experts Enrollment Form to receive two years of free credit monitoring, identity theft protection and insurance. You must enroll online or by mail no later than September 16, 2019. To review a detailed explanation of the services provided in your eligible free, two-year MyIDCare Identity Protection Service package, please click here.
  • Submit an Unreimbursed Loss Claim Form if you incurred any losses that resulted from identity theft or the unauthorized use of your personally identifiable information including your health information. You may be entitled to receive up to $20,000.00 for unreimbursed losses. Examples of reimbursable losses include charges, late fees, declined payment fees, overdraft fees, returned check fees, and any other losses that could have resulted from the cyberattack on the UCLA Health Network. You can be reimbursed for the time you spent addressing these issues up to six hours at $15 per hour. Per the Final Approval Order, the deadline to submit an Unreimbursed Loss Claim Form online or by mail was extended to no later than June 28, 2021.
  • The deadline to submit a Preventive Measure Claim Form was June 18, 2019. We are no longer accepting submissions.

You are eligible to submit one of each Claim Form, but they must be completed and submitted no later than the due dates as described above. Forms received after these deadlines will be deemed untimely and may not be accepted.


Documentation:

If you have any documents supporting your claims, you should submit them as part of your Claim Form submission. Documents supporting your claim must be provided if the documents are reasonably available to you. Documents supporting your claim could include credit card statements, bank statements, invoices or receipts, telephone records, or any other writing that supports your claim.

Supporting documentation should be clear, readable copies, as they will not be returned to you. If you plan on filling online, please have your documentation ready before you begin, as you will not be able to save your progress and return at a later time to finish. Please keep copies of everything you submit, as your claim may be audited and you could be asked to provide additional information to process the claim.


How to Submit Online:

After clicking the buttons below, you will be asked to provide a Unique ID that is found on the Postcard Notice you may have received. While this is not required for online filing, providing it will aid in the processing of your claim. If you have lost your ID, please contact the Claims Administrator. Then, provide your contact information, fill out the form to the best of your ability, upload any documentation, as applicable, then submit it.

Before submitting your Claim Form online, you can preview the Preventive Measure Claim Form in its entirety here, and the Unreimbursed Loss Claim Form in its entirety here.

Select from the forms below:



How to Submit By Mail:

All forms are available for download here or available on request from the Claims Administrator. Fill out the form to the best of your ability, attach any documentation, as applicable, then sign and date it. Then, mail them to the following address:

UCLA Health System
Claims Administrator
P.O. Box 3058
Portland, OR 97208-3058