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: 492 | Average rating: 4.9

5

This was the 1st time I’ve ever had to use this type of service. Hands down would recommend this team for all your injury needs. They were professional, made sure everything was understood and was by my side step by step. I really felt like they were in my corner at all times!
Kathryn Hartnett went above and beyond to meet my needs as a unexpected life change happened. Everyone from the front desk to the back where amazing! Thank you so much!

5

I am very pleased with the team that worked on my case. Very professional, very kind. I will definitely recommend them.

5

I had the pleasure of working with Jeremy and his team. Beyond professional, very in tune with what was all going on for me after my accident. I could not recommend them enough for honestly any of the avenues of business they provide. Truly a kind and moral team to work with.

5

I can’t say enough kind things about David O’Neill, Jody and his entire team. During an incredibly scary and overwhelming time following my grandmother’s accident, they stepped in and made the entire process as seamless as possible.

David and his team were patient, compassionate, and always available to answer our questions, which truly put our minds at ease when we needed it most. Their professionalism and care made a difficult situation feel manageable, and I am so thankful for the work they did and the support they provided our family.

I would highly recommend David O’Neill and his team to anyone needing guidance, advocacy, and genuine care during a challenging time.

5

This is an amazing offer that the company offers! The most important thing is always getting home safely and Safe Ride makes sure that happens!

5

Super helpful in a time of need!! Love knowing I can get home safe with a free ride from a business that cares!

5

Can’t express how clutch this service came when happy hour with the girls evolved into a rowdy night of cocktails and questionable decisions. Glad our safe ride home wasn’t one of them!

5

Enough money to get me home on new years thank you so much

5

Sincere gratitude for the free ride home during the holidays! You are actively keeping our community safe : )

5

So generous to cover transportation costs during the holidays to avoid drinking and driving!! I really appreciate that the company has been doing this for years and values our safety! I hope other companies can follow suit and give back to the Omaha community! Thank you!

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