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: 450 | Average rating: 4.9

5

Dave, Donna, and Kelsey are professional, respectful, and easy to work with. I would recommend them to anyone

5

Attorney O’Brien was with my family from the very day after we were hit by a semi truck on the way back from Chicago and I called to retain his services for myself and family. I always said if I were ever injured in an auto accident I’d call Hauptman O’Brien Wolf and Lathrop. Less than two years after our accident he got my family a very nice settlement. Thanks Tim for your selfless service and dedication to your clients!!

5

I’ve been dealing with this how law firm for years. Hands down best in the country

5

David, Jody & Desirae were great to work with after my car accident. They were helpful & always were available to answer any questions I had. It made dealing with an unfortunate event easier to process & deal with. I highly recommend them!!

5

Very friendly, very helpful, very educated and got me what I deserved.Thank you ..

5

Michael fought the hard fight and got my settlement. Everyone was very professional and very responsive to my emails and calls.

5

Great job and easy to work with .

5

I felt Mike did a awesome job couldn’t have got a better lawyer I would recommend the firm to anyone……Thank you

5

Tim was excellent to work with during a difficult accident case.

5

I was reluctant to deal with lawyers and suing for my injury. Would have settled myself if I’d been offered the cost of my care, but I was put off. My son, who had previously used this firm took me to see them. They pursued avenues for recovery that I never thought of and settled for far, far more than I ever dreamed. They are well worth the time. Kyle McGann was professional and kind.

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