MEDICAL MALPRACTICE INTAKE FORM

Thank you for contacting Hauptman O’Brien concerning your medical malpractice claim.

Due to the complex nature of medical malpractice matters, we have found that the best way to determine if we can be helpful in your case is to have you complete the below questionnaire and provide a summary of you or your loved one’s claim.
Additionally, if you have access to the medical records or death certificate, in the event that the medical error caused one’s death, we kindly request that you submit them along with the completed questionnaire.

We will make every effort to review and respond to your request within five business days.
Please be advised that accepting your submission does not imply representation in your matter. However, we assure you that your information will remain confidential and will not be shared with any other party.

Prior to your submission, it is crucial to note that in the state of Nebraska and Iowa (the only two states our firm is licensed to practice law in) there is a two-year statute of limitations for medical malpractice claims.
This means that any claim must be resolved or filed within two years of the alleged malpractice, or the individual will be forever barred from bringing a claim. While there are exceptions to the statute, such as cases involving minors, continuous treatment, or discovery of the malpractice after the two-year period, it is important to be mindful of these time limitations. If your potential claim is approaching the two-year statute of limitations, we cannot guarantee protection from the statute in the event that it is about to expire and prior to any formal representation agreement between the parties is commenced.

Before you begin the questionnaire, it’s important to understand the Plaintiff’s Burden of Proof in a medical malpractice claim. As the claimant, you must be able to prove the following:

A specific error committed by a nurse, doctor, or other medical professional (not just a bad outcome).

A causal connection between the error and an injury. (It is essential to define how the medical error directly lead to a specific injury) such as impairment, loss of bodily function, or death.)

The injury resulted in damages such as medical expenses, pain and suffering, lost income, etc.

MM slash DD slash YYYY
Please provide a detailed, chronological account of the events leading up to and including your claims of medical malpractice. Be sure to describe the injuries you sustained as a result of the malpractice. Include all relevant dates, the symptoms and diagnoses you experienced, the names of the physicians involved, and the treatments administered for each condition.
To the best of your knowledge, when did the negligence occur?
Who do you believe was negligent?
How was the provider negligent?
Please provide a description of the injuries.
Are the injuries continuing or ongoing?
What is the prognosis for recovery?
Did any subsequent healthcare providers criticize the care provided by the negligent provider?
If yes, what did the subsequent healthcare provider say?
Do you have a copy of the relevant medical records?
Max. file size: 512 MB.
Please upload your records here.

Client Testimonials

Total reviews: 425 |

Average rating: 4.9

5

We have nothing but heartfelt praise for Mike Khalili and his team. He sincerely guided us when we didn’t know where to start. What he did to help us was beyond our expectations and we are grateful to Mike and his team for their professionalism and caring throughout what was a difficult time for us. Mike was always informative, reached out regularly to check on Randy’s well-being and kept us posted on all negotiations. Shout out to Kate for her expertise and help regarding the antique car. We will highly recommend the Hauptman O’Brien firm to our family and friends. We truly appreciate everything you did for us.

5

Thankful to have had such a great perfessional team that looked out for my husband in his time of need .

5

David and the team were amazing. They are most certainly the best in the business, I highly recommend them!

5

The team at Hauptman, O’Brien were amazing. They helped me with my lawsuit and got it resolved so quickly. They gave good advice and they never seemed like all they wanted was my money, they genuinely cared to help me! Would definitely recommend them to anyone who has had an injury accident!

5

What a great idea for everyone involved. We got a free, safe ride home, thanks to Hauptman O’Brien. I love this program and hope they continue offering free rides around New Year’s Day, and St. Patrick’s Day. I’ll take a free ride anytime. Thanks!

5

They answer my questions. Helped me along the way. There was alot of papers that needed to be collected and I trusted to take care of me. After two years I am glad it is done. Thank you Jermery Nicole and Andrea. You made going through this better with everything esle in my life at the time.

5

David and his team were so incredibly helpful! They made a difficult time in my life so much easier. I’m super grateful to them all!

5

I want to thank David C. along with all staff, for the prompt assistance and response to my case.

5

Timothy R. O’Brien and the firm are professional, experienced, and responsive. Tim showed genuine empathy and persistence to get me a fair settlement which was far above what I had been offered without legal counsel.

5

Thank you Michael! My workers compensation case was very complex and had several different factors. Michael was there every step of the way providing guidance and support through a life changing situation. Thank you Mike and the entire staff at Hauptman O’Brien Wolf and Lathrop.

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