Healthcare Medical Negligence Content Form

Healthcare Medical Negligence Content Form

Patient Information

Insurance & Billing

Incident Details

Date of Incident:    Time:

Was the event reported at the time to facility staff? Yes No

Providers & Witnesses

Medical Treatment, Injuries, and Outcome

Have you sought subsequent treatment related to this incident? Yes No

Documentation & Evidence

Documents in your possession related to the incident (check all that apply):

Medical records / charts
Bills, itemized statements, or reports
Photographs or imaging files
Emails or written correspondence
Other

Authorization to Obtain and Release Medical Records

I hereby authorize any medical provider, facility, insurance carrier, or custodian of records to release and disclose copies of medical records, billing records, diagnostic imaging, operative reports, nurse notes, and related information concerning treatment for the incident described above to the designated reviewer(s) for the purpose of investigation, legal review, and potential claim evaluation. This authorization includes mental health records, infectious disease testing, and substance use treatment records to the extent permitted by law.

I understand that I may revoke this authorization at any time by delivering a written notice to the custodian of records identified above, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

HIPAA Privacy Acknowledgment

By signing below I acknowledge receipt of this authorization and that I understand my privacy rights under applicable law. I consent to disclosure of my protected health information as described in this form for the sole purposes of investigation, medical review, and potential legal evaluation related to the incident. This authorization does not obligate any provider or facility to release records beyond that which they are permitted to disclose under law.

Certification and Declaration

I certify, under penalty of perjury, that the foregoing statements are true and correct to the best of my knowledge and belief. I understand that this form is used to document factual information and to authorize release of records for review; completion of this form does not constitute legal advice or the formation of an attorney-client relationship. I further acknowledge that knowingly making a false statement in this document may subject me to civil or criminal penalties under applicable law.

Additional Declarations

Has a complaint, claim, or lawsuit been filed previously in connection with this incident? Yes No

I request that communications regarding this matter be kept confidential to the extent permitted by law. Confidential handling requested

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