First Name:

Last Name:

Street Address:

City: State: Zip Code:

Preferred Phone Number:

Preferred E-mail:

Name of person whose information was stolen:

Age of person who information was stolen:

Did you receive a letter that the social security number was involved?

Did you sign up for the credit monitoring that was offered?

Are you concerned about blackmail from exposure of sensitive medical information?

Are you concerned about financial loss from exposure of credit information?

Are you concerned that you do not know exactly what personal information may have been exposed?

I declare that I am the person named above and that I am authorized to represent the person whose records were stolen. By my signature, the person whose records were stolen is asking the Law Office of Clark Newhall MD JD to represent him or her in a class action lawsuit against the parties alleged to be responsible for the theft of medical billing record information from University Hospital on or about June 2, 2008.