Notice of Intent to Sue (Pre-Suit Notice for Medical Injury) - Arkansas

NOTICE OF INTENT TO FILE ACTION FOR MEDICAL INJURY

(Pursuant to Ark. Code Ann. § 16-114-212)

TABLE OF CONTENTS

1. Sender and Recipient Information
2. Statutory Basis
3. Patient Identifying Information
4. Dates of Treatment in Question
5. Summary of Alleged Wrongful Conduct
6. Known Medical Care Providers
7. Authorization for Release of Medical Records
8. Demand for Production of Medical Records
9. Tolling and Reservation of Rights
10. Method of Service / Proof of Mailing
11. HIPAA-Compliant Authorization (Exhibit A)

1. Sender and Recipient Information

FROM:
[ATTORNEY NAME], Ark. Bar No. [____________]
[LAW FIRM NAME]
[ADDRESS]
[CITY], Arkansas [ZIP]
Telephone: [(___) ___-____]
Email: [____________________]

Counsel for Prospective Plaintiff

TO (sent by United States Certified Mail, Return Receipt Requested):

DATE OF NOTICE: [__/__/____]

RE: Notice of Intent to File Action for Medical Injury Pursuant to Ark. Code Ann. § 16-114-212 — Patient: [PATIENT FULL NAME] (DOB [__/__/____])

2. Statutory Basis

Dear [Recipient]:

This letter constitutes formal NOTICE OF INTENT TO FILE AN ACTION FOR MEDICAL INJURY pursuant to Ark. Code Ann. § 16-114-212. This notice is served within thirty (30) days prior to the expiration of the applicable statute of limitations under Ark. Code Ann. § 16-114-203 for the purpose of triggering the ninety-day (90-day) tolling provision set forth in § 16-114-212.

Counsel for the prospective plaintiff has determined that there is a reasonable basis to assert a claim for medical injury arising out of the care and treatment described below. The information set forth in this notice is intended to satisfy each of the statutory content requirements of Ark. Code Ann. § 16-114-212(a).

3. Patient Identifying Information

The information required by Ark. Code Ann. § 16-114-212(a)(1) is as follows:

[If patient is deceased: The Patient died on [__/__/____]. This notice is sent by [PERSONAL REPRESENTATIVE NAME], duly appointed Personal Representative of the Estate of [DECEDENT NAME] in Case No. [____________] pending in [COUNTY] County Probate Court, Arkansas. A copy of the Letters of Administration is enclosed.]

[If patient is a minor or incompetent: This notice is sent on behalf of [MINOR / INCOMPETENT NAME] by [PARENT / GUARDIAN NAME], the [natural parent / court-appointed guardian] of [MINOR / INCOMPETENT NAME].]

4. Dates of Treatment in Question

The dates of the treatment giving rise to the prospective claim, as required by Ark. Code Ann. § 16-114-212(a)(2), are as follows:

☐ Initial encounter: [__/__/____] — [setting / chief complaint, e.g., "Emergency Department presentation at [HOSPITAL] for acute abdominal pain"];

☐ Subsequent encounters / inpatient course: [DATE RANGE] — [setting / events];

☐ Index event / negligent act or omission: [__/__/____] — [brief description, e.g., "operative procedure during which [EVENT] occurred"];

☐ Date of discharge / discontinuation of care: [__/__/____];

☐ Date injury was discovered or reasonably should have been discovered: [__/__/____].

5. Summary of Alleged Wrongful Conduct

The following summary of alleged wrongful conduct is provided pursuant to Ark. Code Ann. § 16-114-212(a)(2). This summary is preliminary and based on currently available information; it is not intended to be exhaustive and is subject to amendment based on further investigation, including review of complete medical records.

A. Clinical Setting

[Describe in 1-3 sentences the patient's clinical presentation and the care relationship: e.g., "On [DATE], [PATIENT NAME], a [age]-year-old [male/female] with a history of [conditions], presented to [PROVIDER / FACILITY] with [chief complaint]. Care was provided by [PROVIDERS] from [DATE] through [DATE]."]

B. Alleged Departures from the Standard of Care

The prospective plaintiff alleges that the medical care providers identified above departed from the applicable standard of care in one or more of the following respects:

☐ Failure to diagnose or delay in diagnosis of [CONDITION], where the standard of care required [identify required diagnostic action] in light of [identify presenting findings];

☐ Misinterpretation of diagnostic studies, including [specific imaging or laboratory findings] obtained on DATE;

☐ Failure to recognize and respond to clinical deterioration documented on [DATE/TIME], including [specific abnormal vital signs / laboratory values / examination findings];

☐ Failure to obtain timely consultation, intervention, or transfer to [SPECIALTY / HIGHER-LEVEL FACILITY];

☐ Improper medication selection, dosing, route, or monitoring, specifically [identify medication and error];

☐ Surgical or procedural error during [PROCEDURE] on DATE, including [identify error];

☐ Failure to obtain valid informed consent for [PROCEDURE / TREATMENT];

☐ Failure to communicate critical results to [patient / covering provider / receiving facility];

☐ Premature discharge despite documented clinical instability;

☐ Inadequate post-procedure or follow-up care, including [identify deficiency];

☐ Other: [identify].

C. Resulting Injury

As a result of the foregoing conduct, [PATIENT NAME] suffered the following injuries: [identify injuries — e.g., "delayed diagnosis of pulmonary embolism with consequent right-heart strain and prolonged hospitalization", "anastomotic leak requiring emergent re-operation, prolonged ICU stay, and permanent ostomy", "death on [DATE]"].

The damages claimed include past and future medical expenses, past and future lost earnings and earning capacity, past and future physical pain and suffering, mental anguish, permanent impairment, and [if applicable] mental anguish and loss-of-consortium damages of statutory beneficiaries under Ark. Code Ann. § 16-62-102(f).

6. Known Medical Care Providers

The names and addresses of the medical care providers known to the prospective plaintiff to be involved in the alleged medical injury, as required by Ark. Code Ann. § 16-114-212(a)(3), are as follows:

This list is based on currently available information and is not intended to be exhaustive. Additional providers may be identified upon receipt of complete medical records.

7. Authorization for Release of Medical Records

Pursuant to Ark. Code Ann. § 16-114-212(a)(4), the prospective plaintiff has executed a written authorization for the release of medical records. The authorization is provided as Exhibit A to this notice and complies with the requirements of 45 C.F.R. § 164.508 (HIPAA Privacy Rule).

The authorization permits each named medical care provider to obtain and release all pertinent medical records related to the allegations described in this notice.

8. Demand for Production of Medical Records

Pursuant to Ark. Code Ann. § 16-114-212(b), and in conjunction with this notice, the prospective plaintiff hereby REQUESTS PRODUCTION OF COPIES OF ALL MEDICAL RECORDS in the possession, custody, or control of each named medical care provider relating to the care and treatment of [PATIENT NAME].

The records requested include, without limitation:

☐ All physician, nursing, therapist, and ancillary-provider notes and progress notes;

☐ All admission, discharge, and transfer records;

☐ All physician orders;

☐ All laboratory, pathology, and radiology reports and the underlying images and slides;

☐ All operative, anesthesia, and procedure records;

☐ All medication administration records;

☐ All telemetry and electronic monitoring records;

☐ All consent forms;

☐ All correspondence, telephone notes, and electronic messages;

☐ All billing records; and

☐ Any other documents reflecting the care and treatment of [PATIENT NAME].

Records should be produced to undersigned counsel within thirty (30) days of receipt of this notice, as contemplated by Ark. Code Ann. § 16-114-212(b). Failure to produce records within that period may give rise to an expedited declaratory action under § 16-114-212(b).

A reasonable, statutorily authorized copying fee may be charged in accordance with Ark. Code Ann. § 16-46-106.

9. Tolling and Reservation of Rights

By serving this notice within thirty (30) days prior to the expiration of the applicable statute of limitations, the prospective plaintiff invokes the ninety-day (90-day) tolling provision set forth in Ark. Code Ann. § 16-114-212(a). The statute of limitations applicable to the claim described above is therefore tolled for ninety (90) days from the date of service of this notice as to each medical care provider named herein.

The prospective plaintiff reserves all rights under Arkansas law, including without limitation the right to:

☐ Amend, supplement, or expand the allegations summarized in this notice;

☐ Identify and join additional parties upon receipt of complete medical records;

☐ Pursue claims for vicarious liability against employers, principals, or apparent principals of the named providers;

☐ Pursue claims for institutional / corporate negligence (credentialing, staffing, policy);

☐ Pursue claims for lack of informed consent;

☐ Pursue claims for gross negligence and punitive damages;

☐ [If applicable] Pursue wrongful-death claims under Ark. Code Ann. § 16-62-102 and survival claims under § 16-62-101.

This notice is not, and shall not be construed as, a waiver of any right, claim, or remedy available to the prospective plaintiff or to any statutory beneficiary, and is sent without prejudice.

10. Method of Service / Proof of Mailing

This notice is being served upon each addressee identified in Section 1 by United States Certified Mail, Return Receipt Requested, with article numbers as follows:

A duplicate of this notice, together with the proof of certified mailing and the signed return receipts upon their return, will be retained in counsel's file as evidence of service for purposes of computing the tolling period under Ark. Code Ann. § 16-114-212(a).

Sincerely,

________________________________
[ATTORNEY NAME], Ark. Bar No. [____________]
[LAW FIRM NAME]
Attorney for Prospective Plaintiff

Enclosures:

• Exhibit A: HIPAA-Compliant Authorization for Release of Medical Information
• [If applicable] Letters of Administration / Letters Testamentary
• [If applicable] Birth certificate / guardianship order

11. HIPAA-Compliant Authorization (Exhibit A)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

(45 C.F.R. § 164.508)

I, [PATIENT NAME / PERSONAL REPRESENTATIVE NAME ON BEHALF OF [PATIENT/DECEDENT]], hereby authorize each medical care provider listed below to use and disclose my [or [DECEDENT'S]] protected health information as described in this authorization.

Providers authorized to use and disclose information:

[List each named provider and facility from Section 6.]

Information to be disclosed:

All medical records, billing records, radiology images and reports, pathology slides and reports, laboratory results, mental-health records (if any), substance-use treatment records (if any, separately initialed below), HIV/AIDS-related information (if any, separately initialed below), and any other health information related to the care and treatment of the Patient.

☐ I authorize release of substance-use treatment records (42 C.F.R. Part 2): [INITIAL] _______
☐ I authorize release of HIV/AIDS-related information: [INITIAL] _______
☐ I authorize release of mental-health and psychotherapy notes: [INITIAL] _______

Recipient(s) of information:

[ATTORNEY NAME], [LAW FIRM NAME], and any agents, paralegals, experts, and consultants retained by the law firm in connection with the prospective claim.

Purpose of disclosure:

Investigation, evaluation, prosecution, and resolution of a potential claim for medical injury under Arkansas law.

Expiration:

This authorization shall expire on [__/__/____] [or upon final resolution of the matter, whichever is later].

Right to revoke:

I understand that I have the right to revoke this authorization at any time by providing written notice to the disclosing provider, except to the extent that action has already been taken in reliance on the authorization. Revocation must be sent in writing to the provider's privacy officer.

Re-disclosure:

I understand that information disclosed pursuant to this authorization may no longer be protected by federal privacy regulations and may be re-disclosed by the recipient.

Conditioning:

I understand that my treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.

Right to copy:

I understand that I am entitled to a copy of this signed authorization.

________________________________
[PATIENT NAME / AUTHORIZED REPRESENTATIVE]

[If signed by representative:] Authority to sign: ☐ Personal Representative (Letters attached) ☐ Parent of minor ☐ Legal guardian (order attached) ☐ Healthcare power of attorney (attached)

Sources and References

Statutory Authority

• Ark. Code Ann. § 16-114-212 — Pre-suit notice; tolling of statute of limitations (90-day toll)
• Ark. Code Ann. § 16-114-203 — Statute of limitations (two years from date of wrongful act; one year from foreign-object discovery)
• Ark. Code Ann. § 16-114-209 — Reasonable Cause Affidavit (separate, applies at filing of complaint)
• Ark. Code Ann. § 16-114-201 — Definitions (medical care provider; medical injury)
• Ark. Code Ann. § 16-46-106 — Patient access to medical records
• Ark. Code Ann. § 16-62-102 — Wrongful death
• 45 C.F.R. § 164.508 — HIPAA authorization requirements
• 42 C.F.R. Part 2 — Confidentiality of substance-use treatment records

Practice Notes — Arkansas-Specific

• The § 16-114-212 notice is a TOLLING mechanism, not a mandatory pre-suit notice. If the SOL is not in jeopardy, file the complaint directly.
• Send by certified mail, return receipt requested, to each defendant provider. A blanket notice or one-copy-to-all approach is risky.
• Calendar both the original SOL date and the tolled date (original SOL + 90 days). Lock the file.
• The Reasonable Cause Affidavit under § 16-114-209 is a separate filing-stage requirement and is not part of this notice.
• Arkansas does NOT have an apology / sympathy statute. Statements made by providers in response to this notice are not statutorily protected and may be admissible.
• If the provider fails to produce requested records within 30 days, an expedited declaratory action is available under § 16-114-212(b).

Disclaimer

This template is provided for informational purposes only and does not constitute legal advice. Statute-of-limitations calculation and notice service are time-critical. Confirm current statutory text on arkleg.state.ar.us and consult a qualified Arkansas attorney before service.