Notice of Intent to Sue for Medical Malpractice

NOTICE OF INTENT TO SUE FOR MEDICAL MALPRACTICE

NOTICE SENT VIA:

☐ Certified Mail, Return Receipt Requested
☐ Registered Mail
☐ Personal Service
☐ Process Server
☐ Other Verifiable Method: [________________________________]

Date of Mailing/Service: [__/__/____]

Tracking Number (if applicable): [________________________________]

TO:

Healthcare Provider/Facility:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

AND TO (if applicable):

Additional Healthcare Provider:
[________________________________]
[________________________________]
[________________________________]

Insurance Carrier/Risk Management:
[________________________________]
[________________________________]
[________________________________]

FROM:

Claimant/Patient:
[________________________________]
[________________________________]
[________________________________]

AND/OR

Attorney for Claimant:
[________________________________]
[Law Firm Name]
[________________________________]
[________________________________]
Telephone: [________________________________]
Email: [________________________________]

RE: NOTICE OF INTENT TO FILE MEDICAL MALPRACTICE ACTION

Patient Name: [________________________________]
Date(s) of Treatment: [__/__/____] through [__/__/____]
Facility/Location of Treatment: [________________________________]

I. STATUTORY NOTICE

PLEASE TAKE NOTICE that the undersigned, on behalf of [________________________________] ("Claimant"), hereby provides formal notice of intent to commence a medical malpractice action against you pursuant to [________________________________] [cite applicable state statute].

This notice is provided not less than [____] days before the anticipated filing of a lawsuit, as required by law.

II. IDENTIFICATION OF CLAIMANT

Full Legal Name: [________________________________]

Date of Birth: [__/__/____]

Social Security Number (last 4 digits): XXX-XX-[____]

Current Address:
[________________________________]
[________________________________]
[________________________________]

Telephone: [________________________________]

Email: [________________________________]

III. IDENTIFICATION OF HEALTHCARE PROVIDERS

The following healthcare providers are the subject of this notice:

Provider 1:

Name: [________________________________]
Type: ☐ Physician ☐ Hospital ☐ Clinic ☐ Nurse ☐ Other: [____________]
Specialty: [________________________________]
Address: [________________________________]
License Number: [________________________________]

Provider 2 (if applicable):

Name: [________________________________]
Type: ☐ Physician ☐ Hospital ☐ Clinic ☐ Nurse ☐ Other: [____________]
Specialty: [________________________________]
Address: [________________________________]
License Number: [________________________________]

Provider 3 (if applicable):

Name: [________________________________]
Type: ☐ Physician ☐ Hospital ☐ Clinic ☐ Nurse ☐ Other: [____________]
Specialty: [________________________________]
Address: [________________________________]
License Number: [________________________________]

IV. FACTUAL BASIS OF CLAIM

A. Description of Medical Treatment

On or about [__/__/____], Claimant sought medical treatment from the above-named healthcare provider(s) for:

[________________________________]
[________________________________]
[________________________________]

The medical treatment at issue included:

☐ Initial consultation and examination
☐ Diagnostic testing and evaluation
☐ Surgical procedure(s)
☐ Medication prescription and management
☐ Inpatient hospital care
☐ Emergency room treatment
☐ Post-operative care
☐ Other: [________________________________]

B. Chronology of Events

[Provide detailed chronology of relevant medical treatment and events]

Date: [__/__/____]
[________________________________]
[________________________________]

Date: [__/__/____]
[________________________________]
[________________________________]

Date: [__/__/____]
[________________________________]
[________________________________]

Date: [__/__/____]
[________________________________]
[________________________________]

V. STANDARD OF CARE

The applicable standard of care required the healthcare provider(s) to:

1. [________________________________]

2. [________________________________]

3. [________________________________]

4. [________________________________]

VI. ALLEGED NEGLIGENCE

A. Manner in Which Standard of Care Was Breached

It is alleged that the healthcare provider(s) breached the applicable standard of care in the following manner(s):

☐ Failure to Diagnose: [________________________________]

☐ Misdiagnosis: [________________________________]

☐ Delayed Diagnosis: [________________________________]

☐ Surgical Error: [________________________________]

☐ Medication Error: [________________________________]

☐ Failure to Obtain Informed Consent: [________________________________]

☐ Failure to Order Appropriate Tests: [________________________________]

☐ Failure to Refer to Specialist: [________________________________]

☐ Failure to Monitor Patient: [________________________________]

☐ Premature Discharge: [________________________________]

☐ Hospital/Facility Negligence: [________________________________]

☐ Nursing Negligence: [________________________________]

☐ Other: [________________________________]

B. Specific Acts or Omissions

The specific negligent acts or omissions include:

1. [________________________________]
   [________________________________]

2. [________________________________]
   [________________________________]

3. [________________________________]
   [________________________________]

VII. INJURIES AND DAMAGES

A. Nature of Injuries

As a direct and proximate result of the alleged negligence, Claimant has suffered the following injuries:

☐ [________________________________]
☐ [________________________________]
☐ [________________________________]
☐ [________________________________]

B. Causation

The alleged negligence caused the above injuries because:

[________________________________]
[________________________________]
[________________________________]

C. Type of Damages Claimed

Economic Damages:
☐ Past medical expenses: $[________________________________]
☐ Future medical expenses (estimated): $[________________________________]
☐ Past lost wages: $[________________________________]
☐ Future lost earning capacity: $[________________________________]
☐ Other economic losses: $[________________________________]

Non-Economic Damages:
☐ Physical pain and suffering
☐ Mental anguish and emotional distress
☐ Loss of enjoyment of life
☐ Permanent disability or impairment
☐ Disfigurement
☐ Loss of consortium

D. Estimated Total Damages

The total estimated damages sought exceed $[________________________________].

VIII. EXPERT CONSULTATION (if required by jurisdiction)

☐ Claimant has consulted with a qualified medical expert who has reviewed the medical records and related materials and has concluded that there is a reasonable basis to believe that the standard of care was breached and that such breach caused Claimant's injuries.

☐ An Affidavit of Merit from a qualified medical expert is attached hereto.

☐ The expert's name and qualifications are:
[________________________________]
[________________________________]

IX. AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Attached hereto as Exhibit A is an Authorization for Release of Protected Health Information, executed by Claimant, authorizing the release of Claimant's medical records related to the care at issue.

[If required by jurisdiction, include HIPAA-compliant authorization]

X. SETTLEMENT DEMAND (OPTIONAL)

Claimant is willing to resolve this matter without litigation for the sum of $[________________________________], which represents fair and reasonable compensation for the injuries, damages, and losses sustained.

This demand remains open for [____] days from the date of this notice.

XI. REQUEST FOR RESPONSE

Pursuant to [________________________________], you are requested to respond to this Notice of Intent within [____] days of receipt.

Your response should include:

☐ A statement accepting or denying the allegations
☐ A statement of any defenses
☐ Any relevant information regarding the care provided
☐ Contact information for your insurance carrier and/or legal counsel

XII. STATUTE OF LIMITATIONS NOTICE

Please be advised that this Notice of Intent tolls the applicable statute of limitations pursuant to [________________________________].

The statute of limitations for this claim is scheduled to expire on [__/__/____].

Filing of this notice extends the time to file by [____] days.

XIII. FUTURE COMMUNICATIONS

All future communications regarding this matter should be directed to:

Attorney for Claimant:
[________________________________]
[________________________________]
[________________________________]
Telephone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

XIV. PRESERVATION OF EVIDENCE

You are hereby notified to preserve all documents, records, and tangible items related to Claimant's medical treatment, including but not limited to:

☐ All medical records and charts
☐ All diagnostic test results, images, and reports
☐ All correspondence related to Claimant's care
☐ All billing records
☐ All incident reports
☐ All quality assurance or peer review materials
☐ All electronic medical records
☐ Any physical evidence related to the treatment

Destruction, alteration, or concealment of any such evidence may result in sanctions and adverse inferences.

XV. CLOSING

If the alleged negligence is not resolved within the time required by law, Claimant intends to file a medical malpractice lawsuit seeking compensatory damages, and where applicable, punitive damages, costs, and attorney's fees.

DATED: [__/__/____]

Respectfully submitted,

______________________________________
[Attorney Name]
[State Bar No.]
[Law Firm Name]
[Address]
[City, State ZIP]
[Telephone]
[Email]

Attorney for Claimant

VERIFICATION (if required)

STATE OF [________________________________]
COUNTY OF [________________________________]

I, [________________________________], declare under penalty of perjury that I am the Claimant in the above matter, that I have reviewed this Notice of Intent, and that the facts stated herein are true and correct to the best of my knowledge.

______________________________________
[Claimant Signature]

DATED: [__/__/____]

ATTACHMENTS CHECKLIST

☐ Exhibit A: Authorization for Release of Medical Records (HIPAA Authorization)
☐ Exhibit B: Affidavit of Merit (if required)
☐ Exhibit C: Relevant Medical Records Summary
☐ Exhibit D: Itemization of Damages
☐ Exhibit E: Expert Qualifications (if required)

STATE-SPECIFIC NOTICE REQUIREMENTS

Michigan (MCL § 600.2912b)

• Notice Period: 182 days before filing (may be reduced to 91 days in certain circumstances)
• Response Period: Healthcare provider has 154 days to respond
• Contents Required: Statement of factual basis, applicable standard of care, manner of breach, action that should have been taken, causation, names of all physicians involved
• Tolling: Statute of limitations tolled during notice period

California (Cal. Code Civ. Proc. § 364)

• Notice Period: 90 days before filing
• Contents Required: Legal basis of claim, type of loss sustained, nature of injuries
• Tolling: Statute of limitations tolled for up to 90 days

Florida (Fla. Stat. § 766.106)

• Notice Period: 90 days before filing
• Pre-Suit Investigation: Required under § 766.203
• Contents Required: Intent to initiate litigation, HIPAA authorization
• Response Period: Provider has 90 days to investigate and respond

Nevada (Nev. Rev. Stat. § 41A.071)

• Affidavit Required: Must be supported by medical expert affidavit
• Contents Required: Medical expert's opinion that standard of care was breached

Maine (24 M.R.S. § 2903)

• Notice Period: 90 days before filing
• Mandatory Screening: Pre-litigation screening panel review required

This template is provided for general informational purposes only. Pre-suit notice requirements vary significantly by jurisdiction. Failure to comply with notice requirements may result in dismissal of your claim. Always consult with an attorney licensed in your state before sending any pre-suit notices.