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: 477 | Average rating: 4.9

5

David O’Neill at Hauptman, O’Brien Personal Injury Lawyers handled both of our cases and did excellent work. He communicates clearly, explains every step, returns calls, and follows through. Both cases moved forward smoothly with no confusion and no wasted time. If you need a personal injury attorney, contact David O’Neill because you will feel informed and supported from start to finish.

5

Really caring people who get the job done

5

Personal injury law, it’s all they do

5

Michael Khalili represented me for a workman’s comp claim. He was amazing. Michael went over the process so I fully understood, he was in constant contact with me so I did not have to worry about how things were going. Michael was very professional and knowledgeable. I would highly recommend Michael and this firm.

5

Good experience definitely have my recommendation!!!

5

Had a great experience with Hauptman, O’Brien. Beyond the friendly, helpful staff, our claim was handled quickly!

5

I had a pleasant and no fuss experience, Thanks to the Bellevue team at Hauptman, O’Brien.

5

Wonderful people amazing people to work with and get to know

5

Tim O’Brien was a fantastic lawyer to work with. Mr. O’Brien and his staff went above and beyond for my dad who was a victim of personal injury by a motorist. Their knowledge of the law, and personal care to my case stood out from other attorneys in their field. Hauptman O’Brien Law firm is highly recommended for anyone seeking legal counsel or representation They went the extra mile for our family, time and time again. Thank you from the bottom of our hearts. -Steve

5

Everyone at the Bellevue Location was amazing. I was kept informed on how my case was going with each step. I was not looked at as dollar sign but has a person who was hurt. The compassion, and knowledge of the laws by the staff and David was amazing. I hope if you’re looking for an attorney you chose them to represent you. Thank you for taking care of my case.

It Doesn't Cost You Anything to Talk to an Attorney
No Attorney Fees Unless You Win
Do You Have a Case?
Back To Top