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.

All fields should be filled with the information for the individual that was injured.

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

4.9 rating of 597 reviews
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Marisa Cohn avatar

Marisa Cohn

7 days ago

I would like to send a huge THANK YOU to David O'Neal and everyone at Hauptman O'brien. They were so wonderful to work with. They went above and beyond with helping me through my accident and navigating medical. I highly recommend hiring David for your personal injury needs. You cannot go wrong.

Reginald B York IV avatar

Reginald B York IV

11 days ago

As a college educated working professional, I never wanted or thought I or my family would need the services of a personal injury attorney. When someone in our immediate family was involved in an accident, my wife and I thought we could navigate the insurance process on our own, (after all we weren’t looking to profit from it). We quickly realized the process has become complicated and can turn into a full time job, costing our family in ways we never even dreamed. While I pray we never find ourselves in a situation to need their services again. David will be my first call. Everyone from top to bottom was patient and understanding. They walked us through the process and advised us along the way, filling in the gaps that hospitals, insurance companies and representatives failed to provide. Thanks to David and his wonderful team our family was able to focus on the emotional and physical healing while they found resolution and we were able to move on.

Chris M avatar

Chris M

13 days ago

David and his team were great and made the whole process seamless. Would highly recommend them to anyone seeking a personal injury lawyer.

Della Farris avatar

Della Farris

14 days ago

Choosing Hauptman ,O'Brien , Wolf & Lathrop for my personal injury lawsuit, was one of my better decisions . They were always available & considerate to us . We were kept updated & informed all the way through . Jeremy & Nicole were awesome.. I would highly recommend.

Paulette Henderson avatar

Paulette Henderson

19 days ago

David O’Neill, Jody Bowman & Desiree at the Bellevue Nebraska location were amazing! They explained things thoroughly, It was easy to communicate with them. They outlined exactly the documentation that was needed. They helped us through every step of the process and kept us informed of the progress. It was a pleasure working with them, and we are extremely satisfied with the outcome. I highly recommend them, they are professional, knowledgeable and handle every aspect with efficiency.

Linda C avatar

Linda C

29 days ago

A little over 2 yrs ago I walked through the doors @ Hauptman O’Brian Wolf & Lathrop, a little nervous and a little scared. I was in a car accident on the interstate, my car was totaled and I’m thankful to be here. With their help and reassurance that everything will be fine. And it is. Jeremiah Elliott and his fantastic staff kept me well informed through out the process. It took patients on my part and time to heal too. They were always there to answer my question and so kind. I would recommend their legal service’s for any type of situation you might be in. It will only take a little time to tell your story or situation and listen to what they say. They are there to help you through the legal process and protect you. I will say I’m grateful for their compassion and knowledge of the legal process. I couldn’t do it without them. Thanks to them my case was successful.

Dan Aitken avatar

Dan Aitken

1 month ago

Fortunately I haven’t required their legal services, but I have made use of their “Safe Ride Home” program. I feel safer knowing that this service is available for everyone, not just clients, during the holidays.

Connor Villen avatar

Connor Villen

1 month ago

First time getting into a motor vehicle accident and the team was really helpful during this process. The piece that made me feel better to work with the Hauptman Bellevue office was that they were always asking how I was doing. The office really ensured my health and recovery was the priority. They made me comfortable throughout the whole process, and would recommend anyone in a motor vehicle accident to reach out to this office. Thank you all!

Hannah Miller avatar

Hannah Miller

1 month ago

Fantastic job!! I am so grateful they kept me updated through every step of the process. Thank you so much!

Tiera Robinette avatar

Tiera Robinette

1 month ago

Was a pleasure working with the team. They really fought for us

Michael Ciaccio avatar

Michael Ciaccio

1 month ago

Great communication and amazing work this group did with my settlement

Laron Stewart avatar

Laron Stewart

1 month ago

David cripe is very helpful he will get the job done and get you a good amount of money for your case..I would recommend him to anybody that being injured in a accident thank you David and staff…

Sadie Hall avatar

Sadie Hall

2 months ago

David O’Neill and his team were wonderful. I was in a car accident with my young son that left me with no vehicle and a broken arm. I was getting overwhelmed with phone calls from insurance and hospitals while trying to heal and care for my two young sons. David and his team took care of every communication and kept me in the loop about how things were progressing. Definitely recommend as he and his team are very empathetic and professional!

Jeanne Belitz Jr avatar

Jeanne Belitz Jr

2 months ago

Tim and his asst Janet made everything very easy for me the entire time so I could concentrate on healing. They communicated with me every step of the way. I was not rushed or told what to do. They let me make decisions on how we wanted to approach things. I felt heard and I was happy with the outcome. Thank you for your hard work. I will definitely be recommending you.

Chris Hoel avatar

Chris Hoel

2 months ago

With 10 years left until retirement I had an accident at work requiring back surgery. Due to the severity of the injury I am no longer physically able to work. Hauptman, O’Brien, Wolf and Lathrop was able to secure a settlement to help bridge that gap. Without them, I would have nothing.

Danielle Sheets avatar

Danielle Sheets

2 months ago

David and staff were efficient, professional and honest. There was zero time or money wasted, and I couldn’t have been more pleased with the outcome. 10/10 recommend!

Michelle Fibich avatar

Michelle Fibich

2 months ago

David O’Neill did an excellent job on my case. Very professional and thorough with the work he and his team provided.

April Eaves avatar

April Eaves

2 months ago

After the car accident I was a little Beyond Shook Up Mr O'Neal. David was phenomenal he handled my case professionally, made sure all my questions were answered in a timely manner. Got me the settlement I deserve even though I didn't know it. Thank you David O'Neal at Hoffman O'Brien wolf and Lathrop LLC

Virginia H avatar

Virginia H

2 months ago

My attorney, Kyle, at Hauptman O'Brien was fantastic. It was a long process, at no fault of the attorney, and He kept me in the loop of the progress on my case, and fought for our victory until the end. I highly recommend them for their professionalism, care of the little guy, perseverance, and personal dedication to detail.

Doug Banks avatar

Doug Banks

2 months ago

David and his team are amazing. They made a very stressful situation easy to deal with. They handled all the medical bills, and were always there to answer any questions. They truly care about the client. I hope I never have to use them again, but if I do I definitely will. Simply the best.

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