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Have you received a Data Breach Notification Letter?
*
Yes
No
If yes, please attach the copy of the data breach letter/email received from the company
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Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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How would you like the attorney to contact you?
Phone
Email
Who's personal information was affected?
*
Mine
My child
Spouce
Other
What is your relationship with the Company? (Patient, Employee, Customer, etc)
*
Do you plan to relocate within next three years?
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Yes
No
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Confirmation
Have you encountered any instance of actual or attempted identity theft or fraud?
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Fraudulent charges on bank or credit accounts
Loans or other accounts opened in your name
Tax return filled in your name
Medical or health insurance claims filled in your name for care you did not receive
Attempts to open utility, phone, or other accounts in your name
Credit inquiries on your credit report that you did not request
Any alerts that your personal information might be on the dark web
You had to get a new debit/credit card due to suspicious activity
Increase in spam, scam, or phishing emails, call or texts
Increase in stress or anxiety as a result of this data breach
Do you have any criminal record involving alleged acts of fraud, theft, or dishonestly?
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Yes
No
Have you received any additional data breach notifications within the last year?
Yes
No
What other company sent you a data breach letter within the last year?
Are there any other experiences or actions you've taken as a result of the data breach that we haven't yet covered?
Please verify that you are human
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