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: 456 | Average rating: 4.9

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.

5

Fast and great with understanding and communication! Appreciate the work that you guys do!

5

Tim helped me out so much with both of my cases! Awesome lawyer! Thank you so much! Would definitely recommend!

5

Was involved in a serious car accident and broke my neck. My family reached out to this firm and they immediately went to work. If you want someone who has your best interests in mind then look no further. In all honesty I did nothing, they worked hard and handled absolutely everything. And the end result was much better than I could’ve hoped for.

5

Hauptman, O’Brien along with Kathryn Harnett worked hard and stuck it out even when it got tough and I had pretty much given up on any justice in my case. Cheers.

5

I was very happy with the outcome of my case! Highly recommended!

5

I had the pleasure of being represented by Michael Khalili after I was injured in a car accident, and I can honestly say he did an amazing job. He was professional, responsive, and truly cared about my case. Michael kept me informed every step of the way and fought hard to make sure I was taken care of. I highly recommend him to anyone in need of a personal injury attorney!

5

We appreciated all of the support and help we got through the process. And when we did call with a question, we always got a very prompt return call back, with all the answers we needed. Looking back there is no way we could have done this with out the support of the staff at this office. Everything was an open book and we were very happy with the outcome. Thank you for everything!

5

Lawyer was very , polite respectful when he first came out to see me during my Injury , process was very long , but it was all worth the wait , lawyer also made to ensure to check up throughout the whole process also gave me other resources I needed help with . 10/10 customer service all the way & would work with them any other day ! Thank you Kyle for being great

5

They provided the direction we needed and worked hard on our behalf on my husband’s case.

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