Montana Application for Review — Montana Medical Legal Panel (Functional Equivalent of Certificate of Merit)

APPLICATION FOR REVIEW BY THE MONTANA MEDICAL LEGAL PANEL

TO: Director, Montana Medical Legal Panel

Mailing Address: P.O. Box 4248, Helena, MT 59604
Physical Address: [Current MLP office address]
Telephone: [(___) ___-____]

I. CAPTION OF APPLICATION

MLP File No.: [To be assigned by the Panel]

II. CLAIMANT INFORMATION

Full Legal Name: [____________________________________]
Date of Birth: [__/__/____]
Address: [____________________________________]
City, State, ZIP: [____________________], MT [______]
Telephone: [(___) ___-____]
Email: [____________________]

If Claimant is a minor, person under guardianship, or deceased, identify the personal representative or next friend:

Representative Name: [____________________________________]
Capacity: ☐ Parent / ☐ Guardian / ☐ Conservator / ☐ Personal Representative of the Estate / ☐ Other: [____________]
Authority Documentation: [Letters / Court Order / Power of Attorney — attach as Exhibit ____]

III. RESPONDENT HEALTH CARE PROVIDERS

IV. STATUTORY BASIS

This Application is submitted pursuant to the Montana Medical Legal Panel Act, Mont. Code Ann. § 27-6-101 et seq., and specifically Mont. Code Ann. §§ 27-6-105, 27-6-301, and 27-6-302.

Claimant acknowledges that, pursuant to Mont. Code Ann. § 27-6-105, no malpractice claim subject to the Act may be filed in any Montana state district court, justice court, or federal district court sitting in Montana against a health care provider before this Application has been filed and the Panel has rendered its decision.

Pursuant to Mont. Code Ann. § 27-6-702, the running of the applicable statute of limitations is tolled upon the Panel's receipt of this Application and resumes thirty (30) days after the Panel's final decision.

V. STATEMENT IN REASONABLE DETAIL OF THE ELEMENTS OF THE MALPRACTICE CLAIM

A. Care at Issue

1. Claimant first sought care from Respondent(s) on [__/__/____] for the following condition or complaint: [____________________________________________________________].

2. The relevant care, treatment, diagnostic encounters, and surgical procedures occurred between [__/__/____] and [__/__/____] at the following locations: [____________________________________________________________].

3. The chronology of the care at issue is summarized as follows (attach detailed chronology as Exhibit B if needed):

• [__/__/____] — [____________________________________]
• [__/__/____] — [____________________________________]
• [__/__/____] — [____________________________________]
• [__/__/____] — [____________________________________]

B. Acts or Omissions Believed to Constitute Malpractice

Claimant believes the following acts or omissions of the Respondent(s) constitute malpractice and a departure from the applicable standard of care:

☐ Failure to timely and accurately diagnose [____________________];
☐ Failure to order appropriate diagnostic studies, including [____________________];
☐ Misinterpretation of imaging or laboratory results, specifically [____________________];
☐ Negligent surgical performance, specifically [____________________];
☐ Failure to recognize and respond to deteriorating clinical condition, specifically [____________________];
☐ Failure to obtain timely consultation or referral to [specialty: ____________________];
☐ Failure to obtain informed consent for [procedure: ____________________];
☐ Negligent post-procedure monitoring or discharge planning;
☐ Negligent prescription, dosing, or medication management of [____________________];
☐ Negligent supervision of residents, trainees, or ancillary staff;
☐ Negligent credentialing or institutional policies;
☐ Other: [____________________________________________________________].

C. Resulting Injury

4. As a result of the foregoing acts or omissions, Claimant suffered the following injuries and damages: [____________________________________________________________].

5. Claimant first discovered, or through the exercise of reasonable diligence should have discovered, the injury and its causal connection to the Respondent(s)' conduct on or about [__/__/____].

VI. NAMES AND ADDRESSES OF PHYSICIANS, HOSPITALS, AND WITNESSES

A. All Physicians and Hospitals Having Contact with Claimant

B. Other Witnesses

VII. AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

The undersigned Claimant, pursuant to 45 C.F.R. §§ 164.502 and 164.508 (HIPAA), Mont. Code Ann. § 50-16-501 et seq. (Montana Uniform Health Care Information Act), and the rules of the Montana Medical Legal Panel, hereby authorizes the Panel and its director, members, and staff to:

1. Receive, review, and consider all medical, hospital, pharmacy, mental health, and billing records pertaining to Claimant from any of the providers identified herein, for the period from [__/__/____] to the present; and
2. Request such records directly from the providers identified herein.

This authorization expires upon final disposition of this MLP matter and any subsequent litigation arising from the same claim, unless earlier revoked in writing.

______________________________________
[CLAIMANT FULL LEGAL NAME]
Date: [__/__/____]

VIII. STATEMENT OF COUNSEL — MERIT SCREENING

I, [ATTORNEY FULL NAME], Montana State Bar No. [____________], counsel for Claimant, hereby state:

1. I have reviewed the medical records of the care at issue, including the records of each Respondent named in this Application.

2. I have consulted with one or more health care providers with knowledge, education, training, and experience in the relevant specialty or specialties to evaluate the care at issue.

3. Based upon that review and consultation, I have concluded in good faith that there exists a reasonable basis to believe that one or more of the Respondents departed from the applicable standard of care, and that such departure caused or substantially contributed to the injury alleged.

4. This Application is presented in good faith pursuant to Mont. R. Civ. P. 11 and the Montana Rules of Professional Conduct, and not for any improper purpose.

DATED this [____] day of [____________________], 20[____].

______________________________________
[ATTORNEY FULL NAME], Esq.
Montana State Bar No. [____________]
[Firm Name]
[Firm Address]
Telephone: [(___) ___-____]
Email: [____________________]

Attorney for Claimant

IX. SIGNATURE OF CLAIMANT OR COUNSEL

Pursuant to Mont. Code Ann. § 27-6-301, this Application is signed by the Claimant or the Claimant's attorney.

______________________________________
[CLAIMANT FULL LEGAL NAME] (or Attorney for Claimant, as indicated)

Date: [__/__/____]

X. VERIFICATION

STATE OF MONTANA
COUNTY OF [____________________] ss.

I, the undersigned, being first duly sworn upon oath, depose and state that I have read the foregoing Application for Review by the Montana Medical Legal Panel and that the matters stated therein are true to the best of my knowledge and belief, except those matters stated upon information and belief, which I believe to be true.

______________________________________
[CLAIMANT OR REPRESENTATIVE NAME]

SUBSCRIBED AND SWORN to before me this [____] day of [____________________], 20[____].

______________________________________
Notary Public for the State of Montana
Residing at: [____________________]
My Commission Expires: [__/__/____]

[NOTARIAL SEAL]

XI. FILING FEE AND TRANSMITTAL

A filing fee in the amount required by the Montana Medical Legal Panel's current fee schedule is enclosed.

This Application and all attachments are being transmitted to the Director of the Montana Medical Legal Panel by [☐ U.S. Mail / ☐ Hand Delivery / ☐ Other: ____________________] on [__/__/____].

XII. ATTACHMENTS / EXHIBITS

The following are attached and incorporated by reference:

• Exhibit A — Authorization for Release of Medical Records
• Exhibit B — Detailed Chronology of Care (if separately prepared)
• Exhibit C — Relevant Medical Records (organized by provider and date)
• Exhibit D — Imaging Reports and/or Pathology Reports
• Exhibit E — Death Certificate (if applicable)
• Exhibit F — Letters of Authority (guardianship / conservatorship / personal representative, if applicable)
• Exhibit G — [Other: ____________________]

MONTANA-SPECIFIC PRACTICE NOTES

No Separate Certificate of Merit Required. Montana does not impose a separate certificate-of-merit or expert-affidavit requirement at the time the malpractice complaint is filed. The substantive merit-screening function is performed by the Montana Medical Legal Panel under Mont. Code Ann. § 27-6-101 et seq.

Composition of Panel (Mont. Code Ann. § 27-6-401). Six members sit in review of each case. For physician-only claims, three physicians and three attorneys sit. For dentist-only or podiatrist-only claims, three of the relevant specialty and three attorneys sit. For health care facility claims and mixed claims, the composition substitutes facility administrators as appropriate.

Advisory Decision (Mont. Code Ann. § 27-6-606). The Panel's decision is advisory only. Neither the decision nor any statements made before the Panel are admissible in any subsequent court proceeding, except in narrow circumstances specified by the Act.

Tolling (Mont. Code Ann. § 27-6-702). The applicable statute of limitations is tolled from the date the Panel receives the Application until thirty (30) days after the Panel's final decision.

Statute of Limitations (Mont. Code Ann. § 27-2-205). Three-year discovery rule and five-year statute of repose, with a fraudulent-concealment exception.

Apology Statute (Mont. Code Ann. § 26-1-814). Statements of apology, sympathy, or benevolence by health care providers are not admissible to prove liability.

SOURCES AND REFERENCES

• Mont. Code Ann. § 27-6-101 — Short title
• Mont. Code Ann. § 27-6-103 — Purpose
• Mont. Code Ann. § 27-6-105 — Submission of malpractice claim required (jurisdictional)
• Mont. Code Ann. § 27-6-301 — How cases submitted
• Mont. Code Ann. § 27-6-302 — Contents of application
• Mont. Code Ann. § 27-6-401 — Composition of panel
• Mont. Code Ann. § 27-6-606 — Findings of panel — admissibility
• Mont. Code Ann. § 27-6-702 — Tolling of statute of limitations
• Mont. Code Ann. § 27-2-205 — Actions for medical malpractice
• Mont. Code Ann. § 25-9-411 — Medical malpractice noneconomic damages limitation
• Mont. Code Ann. § 26-1-814 — Apology, sympathy, or benevolence — inadmissible
• Mont. Code Ann. § 50-16-501 et seq. — Montana Uniform Health Care Information Act
• Rules of Procedure for the Montana Medical Legal Panel (Mont. Sup. Ct.)
• Montana Medical Legal Panel — official site (montanamedicallegalpanel.org)