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: 414 |

Average rating: 4.9

5

I want to thank David C. along with all staff, for the prompt assistance and response to my case.

5

Timothy R. O’Brien and the firm are professional, experienced, and responsive. Tim showed genuine empathy and persistence to get me a fair settlement which was far above what I had been offered without legal counsel.

5

Thank you Michael! My workers compensation case was very complex and had several different factors. Michael was there every step of the way providing guidance and support through a life changing situation. Thank you Mike and the entire staff at Hauptman O’Brien Wolf and Lathrop.

5

Timothy O’Brien and his team took care of my daughter ..They treated us with Respect, Compassion, like family…
May God continue to bless you all.
The Quintana family ❤️

5

They took the time to explain how it works on an accident claim and they got us every penny available. We don’t owe $700k in hospital bills and we were able to get a good vehicle. They did good for what there was to work with. Hopefully never have to go through this again but if we do, you can bet that I’ll go back to them!! Thank you to Mr Elliot and team!!

5

I’m very thankful for Hauptman O’Brien, Mr Elliott put in the effort for our case. And the results show how much they are for us. All we can say is thank you and God Bless You. We’re blessed with the outcome. Much appreciated

5

David O’Neill and his team really helped me out in a bad situation! They made the process of getting my settlement easy, and did all of the work for me! I would recommend Hauptman, O’Brien Personal Injury Lawyers to anyone I know, and even to those who I don’t know!

5

Having David O’Neill and his team by my side after a major car accident was a huge blessing! We had mountains of doctor bills piling up and I did not truly knowing how to navigate all that on my own. It was so easy to hand everything over to them and not have to worry about that. Having to deal with the months of PT for all of us and surgery after was stressful enough. In the end, I walked away very happy that I chose to go with David O Neill to represent us.

5

I experienced a situation that resulted in a personal injury, and I didn’t hesitate to contact Kyle McGinn with Hauptman, O’Brien. He was extremely knowledgeable and explained precisely what I needed to to and what to expect. He was patient and professional, and I would 10/10 recommend!

5

Many thanks to Tim O’Brian, who helped me get a settlement for a dog bite, much more than I expected. KO

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