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Settlement Administrator PO Box 3240 Portland, OR 97208 …

M 4 011 0 8 .14. 2 014101-CA8356 Questions?Call Toll-Free (877) 846-0588 or Visit AdministratorPO Box 3240 portland , OR 97208 -3240<<mail id>> <<Na me1>> <<Name2>> <<Address1>> <<Address2>> <<City>> <<State>> <<Zip>> <<Foreign Country>> <<Date>> The Shane Group, Inc. v. Blue Cross Blue Shield of MichiganNo. 2 District Court for the Eastern District of MichiganCONSUMER CLAIM FORMIf you are an individual who paid a general acute care hospital in Michigan for healthcare services at any time between January 1, 2006 and June 23, 2014, you are a member of the Settlement Class in a lawsuit against Blue Cross Blue Shield of Michigan ( BCBSM ) and are entitled to submit a claim to share in the Settlement money.

M4011 v.11 08.14.2014 1 01-CA8356 Questions? Cal oll-Fre 877 846-0588 isi www.MichiganHospitalPaymentsLitigation.com Settlement Administrator PO Box 3240

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