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This claim form should be completed if you received a notification from Grays Harbor County Public Hospital District No. 2, Grays Harbor Community Hospital, GHCH Physician Services, LLC d/b/a Harbor Medical Group (collectively “Grays Harbor”) relating to a cyberattack against Grays Harbor’s computer systems that occurred in June 2019 (the “Data Incident”), and you had out-of-pocket expenses, fraudulent charges, lost time spent dealing with the Data Incident, or unreimbursed extraordinary monetary losses as a result of the Data Incident. You may get a payment if you complete this claim form, if the settlement is approved, and if you are found to be eligible for a payment.