Healthcare Malpractice Data Form

HEALTHCARE MALPRACTICE DATA FORM

Purpose: This form collects detailed administrative and clinical information required to initiate a formal review and investigation of an alleged healthcare malpractice event. Completion of this form does not constitute notice of lawsuit; it authorizes the release and compilation of records for investigatory and risk-management purposes.

Patient Information

Date of birth:    Gender: Male Female Other Prefer not to disclose

Insurance and Billing

Incident Details

Date of incident:    Time of incident:

Type(s) of alleged event (check all that apply):
Surgical error Medication error Misdiagnosis Delayed diagnosis Fall Birth injury Restraint/behavioral issue Other (describe below)

Injuries, Treatment, and Outcome

Current status of patient:

Witnesses

Prior Complaints or Claims

Has the patient filed prior complaints, administrative reports, or malpractice claims against any provider involved in this event?
Yes No

Legal and Insurance Representation

Facility Actions and Internal Review

Internal investigation opened:    Risk manager / investigator:

Attachments Checklist

Please indicate items attached or available for review:
Medical records Imaging (films/reports) Operative reports Billing records Photographs Witness statements Other

Authorization to Release Records and Certification

I hereby authorize all healthcare providers, facilities, insurers, and representatives to release medical records, billing records, imaging studies, operative reports, nurse notes, and other relevant information to the facility or its designated representative for purposes of investigating the above-described incident. This authorization includes release to legal counsel, insurers, and peer review committees as necessary for a full review.

I understand that this authorization is limited to records and information reasonably related to the incident described in this form and will expire on: unless earlier revoked in writing to the custodian of records. I understand that revocation will not apply to information already released in reliance on this authorization.

Certification: I certify that the information provided on this form is true and complete to the best of my knowledge and belief. I understand that knowingly providing false information may subject me to civil or criminal penalties under applicable law.

HIPAA Acknowledgment: By signing below I acknowledge that I have been informed that protected health information may be accessed and disclosed consistent with this authorization for investigatory and insurance purposes and that such disclosures are subject to applicable privacy protections.

Signature

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