Get Medical Malpractice Intake Form

Completing the Medical Malpractice Intake Form accurately is crucial for effectively communicating your case details. This guide provides a clear, step-by-step approach to help you fill out the form online with confidence.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering your personal information in the 'Name & Address' section. Fill in your full name and address thoroughly for identification purposes.
3. Provide your Social Security Number (SSN) in the designated field to assist with your case processing.
4. Input your telephone numbers, including home, work, and cell numbers. This information is vital for communication regarding your case.
5. Enter your date of birth. This helps establish your identity and confirms your legal status to file the form.
6. Indicate the person or entity that referred you to this service in the 'Referred by' section.
7. If you have consulted prior legal counsel regarding this matter, please provide that information in the 'Prior Counsel?' section.
8. List the doctors and facilities involved in your case in the 'Doctors/Facilities Involved' section. You can include up to six entries to ensure all relevant parties are noted.
9. In the 'Description of issue' field, clearly describe the circumstances surrounding your malpractice claim to provide context.
10. Specify the date of discovery of the injury due to malpractice. This is important to outline the timeline of your case.
11. Indicate whether you have any prior injuries or health issues. If yes, provide details in the corresponding fields, including the nature of the injuries and the timeline.
12. Respond to whether you are a medical marijuana user by selecting 'Yes' or 'No.'
13. Fill out your health insurance information, including the name of your insurance company, member ID, and group number. This information may influence case handling.
14. Finally, include the contact information of the individual completing the form in the 'Form Completed by' section.
15. Once all sections are completed, review your entries for accuracy, save your changes, and choose to download, print, or share the form as needed.

Start filling out your Medical Malpractice Intake Form online today to ensure your case is processed smoothly.