Muller Law - Indiana Medical Malpractice Web Site - Medical Malpractice Questionnaire

Medical Malpractice Claim Questionnaire

		If you believe that you or someone that you represent has a malpractice claim that you would like to have evaluated, fill in the following information and submit the request. After we receive the information, our nurse or paralegal will review the claim with an attorney and get back to you. If you want to call, the number is 317-574-4500 or 1-888-599-2640. There is no charge or obligation.
	Please remember that a medical malpractice claim must involve substantial damages that are attributable to the malpractice. As a practical matter, that means: medical bills or other economic damages more than $50,000, permanent injury, or death. Use the "Defining" and "FAQ" links to the left, to answer any questions you may have about medical malpractice claims.

1.) Provide information on the person filling out this form:

Name:  
Day Phone:      
Evening Phone:  
Email Address:  
Relationship to the victim of the malpractice:

2.) Provide information on the victim of the malpractice:

Name:  
Date of birth:

3.) Describe the facts of the claim in your own words:

4.) What is the date that the malpractice occurred?

5.) What do you believe was the malpractice?

6.) Whom do you believe committed the malpractice?

7.) What injuries were caused by the malpractice?

8.) What economic damages (medical bills, lost wages, etc.) were caused by the malpractice?

9.) How is the victim of the malpractice today?

10.) Has the claim been reviewed by any other attorney? Yes No

11.) Who was the attorney?

12.) What was the result of that review?

13.) Is there a claim on file now? Yes No

After clicking the "Submit" button below, your information will be emailed to us. We will review this information and get back with you as soon as possible.

Members of the Indianapolis Bar Association, the Association of Trial Lawyers of America (ATLA),
the Indiana Trial Lawyers' Association (ITLA), and the American Society of Law and Medicine (ASLM).
Certified by the National Board of Trial Advocacy (NBTA) in civil litigation.

Miller Muller Mendelson & Kennedy
8900 Keystone Crossing, Suite 1250
Indianapolis, Indiana 46240
317-574-4500 1-888-599-2640 317-574-4501(fax)

homepage: www.millermuller.com
email comments or questions about this web site to: mmmk@millermuller.com

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