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: 443 | Average rating: 4.9

5

It is very beneficial to seek legal counsel when you have been a victim in an accident. A person without legal counsel cannot achieve maximum benefits. It’s just the way it is…. Every day people don’t write the rules, but attorneys can help you live by the rules. Hauptman O’Brien attorneys are thorough, helpful, considerate and patient. I can strongly recommend Kyle McGinn. The process he assisted me with was arduous and lengthy. I am very appreciative of the outcome and the focus on my return to wellness.

5

I’ve had the pleasure of working with your firm twice now, and it’s always been a pleasure. Very professional and courteous, it’s like you took a bad experience and made feel comfortable. Thanks so much for your help.

5

Choosing to work with David was the best decision we made to help us navigate everything after a car accident. He made the whole process seamless and stress free. Couldn’t recommend enough!

5

Professional and caring.
Very detail oriented and fact finding is a priority.
I felt like I found the best, with the HOWL law firm.
Jeremy, Nichole, and Michael…. WOW!!!!!!
They walked me through hell, and have been there throughout the whole process.
I recommend this firm, if you want to know that you are important, and your case matters.
My case is at closing, and I feel comfortable with the case they worked for me….yet, I feel sad, like I am losing some great friends.
Call this firm….they are honest and good people first.

5

I can’t thank Jeremy, Nicole, and Andrea enough for the way they handled my case. After my car accident, I felt overwhelmed and unsure of what to do, but their team stepped in with confidence, compassion, and clear communication every step of the way.
They explained things in a way that actually made sense, fought hard to make sure I was treated fairly, and never made me feel like just another case number.

If you’re looking for attorneys who actually care and know how to get things done — these are your people

5

What a great service, thank you so much for the free ride. I appreciate it so much!

5

I would give more stars if I could best lawyers I’ve ever dealt with would 1000000% recommend

5

I got in a car accident and needed help. Mr. O’Brien helped me with recovering some funds from the accident and I greatly appreciate all they have done for me. They really took care of me.

5

I can express enough how thankful I am for this outstanding team. Quick to answer questions, honest in their evaluation of the case, and great at updating as things progress. I cannot express enough our gratitude for their help with a difficult situation.

5

Jeremy and his team Nicole and Andrea had no doubt they could help with my sons case. They were kind and very helpful and getting some justice for my little boy. After being attacked by a dog with negligent owners we wanted some kind of justice for our son. After reaching out , Jeremy stayed in touch the whole time and kept us updated every step of the way and my son was set up nicely with an education fund through the money he received . If you want a honest, diligent law firm that gets the job done then Hauptman, O’Brien injury lawyers are the best in Nebraska. These people are good at what they do

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