• Maternal Birth Injury Claim Intake Form

    Please provide the details of the maternal birth injury incident and any supporting information so the claim can be reviewed.

  • Claimant and Contact Information

  • Preferred Contact Method*
  • Format: (000) 000-0000.

  • Birth and Incident Details

  • Date of Birth*
     - -
  • Delivery Date*
     - -

  • Injury and Medical Impact

  • Symptoms experienced*
  • Was hospitalization required?*
  • Was the child also affected?*

  • Care Team and Witness Information

  • Were any witnesses present?*

  • Prior Reporting and Supporting Documents

  • Was the incident reported to the hospital or provider?*
  • Was an internal complaint filed?
  • What supporting documents do you have?*
  • Upload a File
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  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Representation and Claim Status

  • Do you currently have legal representation?*
  • Has any claim or lawsuit been filed?*
  • Known deadline or filing date
     - -
  • Known hearing or court date
     - -
  • Should be Empty:
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