AM0121 v.
03
MAIL
ID
Jane Doe I and Jane Doe II, et al. v. Sutter Health
*0000PLACEHOLDER0000*
*400833999999999996* In the Superior Court of California County of Sacramento,
Case No. 34-2019-00258072
Settlement Claim Form
If you are a Settlement Class Member and wish to receive a payment, your completed Claim Form must be
postmarked on or before April 28, 2026, or submitted online by 11:59 p.m. PST on April 28, 2026.
Please read the full Notice of this settlement (available at [Link]) carefully before
filling out this Claim Form. To be eligible to receive any benefits from the settlement obtained in this class action
lawsuit, you must submit this completed Claim Form online or by mail:
ONLINE: Submit a claim at [Link]
MAIL: Sutter Health Analytics Litigation
Settlement Administrator
P.O. Box 4276
Portland, OR 97208-4276
PART ONE: CLAIMANT INFORMATION & PAYMENT METHOD ELECTION
Provide your name and contact information below. It is your responsibility to notify the Settlement Administrator of
any changes to your contact information after the submission of your Claim Form.
FIRST NAME MI LAST NAME
ADDRESS
CITY STATE ZIP CODE
EMAIL ADDRESS
UNIQUE ID
POTENTIAL CASH PAYMENT: You may be eligible to receive a cash payment of a pro rata share of the available
settlement funds not to exceed Ninety Dollars ($90.00) if you logged into Sutter Health’s MyHealthOnline portal for
purposes of addressing your health from June 10, 2015, through March 20, 2020.
Your cash payment will be sent in the form of a check unless you select Venmo, PayPal, or Zelle. If you would like
payment in a different form, please select from the options below:
Venmo Venmo Email:
PayPal PayPal Email:
Zelle Zelle Email:
Check
PART TWO: ATTESTATION
I affirm under the laws of the United States of America and the State of California that between June 10, 2015, and
March 20, 2020, I logged into Sutter Health’s MyHealthOnline portal for purposes of addressing my health, and that all of
the information on this Claim Form is true and correct to the best of my knowledge, information, and belief. I understand
that my Claim Form may be subject to audit, verification, and review by the Settlement Administrator and Court.
– –
DATE:
MM DD YYYY
SIGNATURE
Please keep a copy of your Claim Form for your records.
Questions? Go to [Link] or call 1-888-835-0109.
01-CA40083399