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Jacoby & Meyers Medical Malpractice Case Screening Online Form

Case Screening Online Form

If you believe you have a medical malpractice claim, please complete the following form and submit it for review along with your medical records. We will follow up with you to ensure we have all the information and documents we need to evaluate your claim. In addition, we will follow up with you to confirm payment.

  • Injured Person's Name
  • Person Completing This Request:
  • First Name
  • Last Name
  • Contact Information:
  • Email Address
  • Home phone number
  • Address
  • City
  • State 
  • Zip Code
  • Names of Facility and Doctors whom you claim caused the injury - Defendant(s)(For individual defendants, please include name and specialty if known):
  • Date of Incident:
  • Has the case been filed? Have you discussed this case with another attorney? If so, please identify the attorney:
  • If an attorney has worked on your case, please include the specific allegations or complaints that were filed. If possible, please include a copy of the complaint along with your medical records:
  • Please provide a summary of the event:
  • Please list any information that would not be included within the medical records, such as comments that the patient says a nurse or doctor told them, observations by the family or patient, or other noteworthy information.
  • List specific questions that you would like to see addressed along with any "gut feelings"/issues/allegations that you and/or the patient believes is at issue in the case:
  • Please list the resulting injuries, outcome, or damages from the events:
  • What records are available for review? More importantly, are the records from the potential defendants available for review and for what time frame?
  • Are there any deadline issues or dates to be aware of?
  • Has the case been reviewed by any other firms, nurses, or experts? If so, who reviewed them and what is the reason you want another review? What was previously reviewed? Do you have a copy of the prior opinion?

We require the Medical Records from the date of injury.