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: 433 |

Average rating: 4.9

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

5

David and his team were great to work with. They handled the claim process, all negotiations, and my medical bills due to my car accident. This was a huge support which allowed me to focus on recovering from my injuries. Thank you David and team!

5

Will recommend to others that need this type of service. Everything was professionally taken care of and I appreciated the manner I was treated as a client.

5

David O’Neill and the entire team was great. They were honest and upfront and did a fantastic job helping me through my lawsuit. Would definitely recommend to anyone who gets into an accident.

5

David was professional and kept me up to date on my case during the whole process. He handled everything and got me compensation beyond what I had expected!! If I could give more than 5 stars I would. Definitely recommend him and the firm for any personal injuries!!! Thank you so much David!!

5

Great place! everyone was super nice and amazing would recommend this place!

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!

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