Healthcare Medical Malpractice Intake Form

Healthcare Medical Malpractice Intake Form

Patient Information

Date of Birth:    Gender: Male Female Other / Non-binary Prefer not to say

Emergency Contact

Insurance & Billing

Representing Party / Reporting

Relationship to Patient:    If Attorney, Firm:

Incident Details

Date of Incident:    Time:

Were photographs, imaging, or other evidence preserved? Photos Imaging Documents/Records None known

Injuries, Medical History & Treatment

Medical Records Authorization & HIPAA Acknowledgement

I authorize any physician, hospital, clinic, health plan, custodian of records, or other medical provider to release medical records and other protected health information as is necessary to evaluate the facts, injuries, and treatment related to the incident described above. This authorization includes operative reports, progress notes, imaging studies, billing records, and diagnostic test results.

Authorization expires on:    I specifically authorize release of:

Operative reports Progress notes Imaging and radiology reports Billing and itemized statements

I acknowledge receipt of the Notice of Privacy Practices for the purpose of this intake and understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance thereon.

I authorize the release of my health information to my attorney or designated representative: Yes No

Prior Claims / Relevant Legal Matters

Have you previously filed a complaint, claim, or lawsuit concerning this condition or provider? Yes No

Certification and Acknowledgements

By signing below I certify under penalty of perjury that the information provided in this intake form is true and accurate to the best of my knowledge. I understand that knowingly providing false information may jeopardize my claim and may be subject to civil or criminal penalties.

I understand that this intake form is for the purpose of evaluating a potential medical malpractice matter and does not create an attorney-client relationship unless expressly agreed in a separate written retainer agreement. I acknowledge that I am responsible for informing the receiving party of any additional providers or records not listed herein.

I understand that certain statutes of limitation apply to medical malpractice claims and that timely preservation of evidence and records may be required. I have been advised to preserve relevant evidence, imaging, and documents where possible.

Sign Now