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.

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

4.9 rating of 576 reviews
Leave a review
Virginia H avatar

Virginia H

25 days 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.

Pat Hartfield avatar

Pat Hartfield

1 month ago

I highly recommend Klye McGinn as an injury lawyer. Klye went over and beyond with my mom. My mom is in the early stages of Alzheimer’s and Kyle was patient, caring, and listen to her concerns. He took the time to explain thing to my mom, over and over again as required. His professionalism, energy and experience showed when it came time to deal with the big insurance company. He did much more than I expedite. He worked very hard with the other insurance company and doctors to get the required documentation needed. Thanks, Kyle, for a seamless transition. My mom was very pleased with her settlement. Thank You Judy Woods

McKinzie Arneson avatar

McKinzie Arneson

1 month ago

I never received my safe ride home voucher but they reached out to me and made sure I would get one, I really appreciate the gesture! So awesome of them to do so!

Neil Reynolds avatar

Neil Reynolds

1 month ago

I think this is a great idea(Offering a Uber ride) that this Law firm is doing. As someone who worked in Law Enforcement for over 28 yrs. I've seen my share of accidents involving someone who was driving while impaired. This frim is providing a service that benifits the community. Programs like this can make a real difference. They are giving a safe & easy alternative when someone otherwise may make a risky decision. It's encouraging to see a local business step up in this manner.

Kelly King avatar

Kelly King

2 months ago

Kyle has been amazing! I went to them right after i was injured and they dialed right in to the process and I did not have to look back. I do not know what I would have done without them. By far the best company out there. I would highly recommend them.

Travis Falk avatar

Travis Falk

2 months ago

Jeremy did a great job with my case. He kept me informed and had my best interest. I recommend this firm to fight for your rights during a difficult time.

Shanelle Clark avatar

Shanelle Clark

2 months ago

They were friendly, efficient, and handled everything, which gave me peace of mind throughout the process. They advocated for me when Progressive was pushing back, and I was very pleased with the service and the way my case was handled. Jeremy was especially great to work with. He explained the process clearly, made sure I understood everything, and kept me informed every step of the way.

patrick morehead avatar

patrick morehead

3 months ago

Tim was absolutely outstanding from start to finish. His hard work, dedication, and professionalism made all the difference in our case, and thanks to his persistence we were able to win. He kept us informed throughout the entire process, answered every question we had, and truly fought for us every step of the way. You can tell Tim genuinely cares about his clients and puts everything he has into getting the best possible outcome. If you want a lawyer who is knowledgeable, dependable, and willing to go the extra mile, I highly recommend Tim. We are beyond grateful for everything he did for our family.

della brasuhn avatar

della brasuhn

3 months ago

We are very happy with David he was always very polite and respectful. Thank you so much for.

Jake Fuller avatar

Jake Fuller

3 months ago

Michael Khalili did a great job working my case and keeping me informed each step of the way while getting my desired outcome. I would highly recommend .

Marge Fields avatar

Marge Fields

4 months ago

My case ended about a year ago, but I just want to give a shout out to Tim OBrien for all he did for me after my accident. I didn’t have any idea what to do or where to begin and he walked me through the whole time. He made sure I understood everything and always kept in touch with me through the whole process. I would recommend this law firm to anyone!!

Maurice Fox avatar

Maurice Fox

4 months ago

Very helpful and explaining the process Step-by-step David and his staff done a great job keeping me informed of every step of the process

Emily Czyz avatar

Emily Czyz

4 months ago

David’s team was amazing! I had a very unique situation and not a lot of hope. David took on my case, went above and beyond to help me. They were open with me, told me the process step by step and made sure I had everything I needed. We had a better outcome than I ever anticipated, I can’t thank him and his team enough.

Mike Dahir avatar

Mike Dahir

4 months ago

Excellent people to work with!!! Highly recommend.

Nikki Green avatar

Nikki Green

4 months ago

Thank you so much for the St. Patrick’s Day safe ride home. It was such an easy process! I appreciate the opportunity to use it.

Sam Farris avatar

Sam Farris

4 months ago

Great people to work with. Very enjoyable experience. Thank you guys very much.

DeAnna McSorley avatar

DeAnna McSorley

4 months ago

Absolutely the best around. They work extremely hard to get done what’s needs done and what you deserve. Would give 10 stars if it would let me.

Laron Stewart avatar

Laron Stewart

5 months ago

David cripe is a amazing attorney he will fight for you.

john lucky avatar

john lucky

5 months ago

Great people who really care

Dan Nelson avatar

Dan Nelson

5 months ago

Mike Khalili and his team were great to work with after my accident. They were always responsive, patient with my questions, and really helped me understand what was happening throughout my workers’ comp/personal injury case. It’s a stressful process, but they made it feel much more manageable. I truly appreciate their help and would absolutely recommend Mike and his team to anyone needing a workers’ comp attorney.

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