First Name
*
Last Name
*
Phone Number
*
Email
*
Did you receive notice that your personal information was exposed in a data breach?
*
Yes
No
Select the medical facility that sent the notice:
*
Lake Charles Memorial Health System
Sequoia Benefits and Insurance Services
Connexin Software, Inc.
OneTouchPoint
Other
Name of the Facility
*
What year were you notified of the data breach?”
*
Have you noticed any suspicious activity regarding your personal information that may have been compromised?
*
Yes
No
Please briefly explain why you are contacting us.
Submitting this information DOES NOT create an attorney client relationship. By submitting this form, you agree to receive recurring text messages that may be sent by an autodialer. Consent is not a condition of purchasing goods or services.
utm_term
Submit
Should be Empty: