Infection or Sepsis Misdiagnosis Claim Intake Form
Use this form to share the details of a suspected missed, delayed, or incorrect infection or sepsis diagnosis so the intake team can review your claim request.
Claimant Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Relationship to Patient
Self
Spouse/Partner
Parent/Guardian
Child
Other
If Other, please specify relationship
Medical Event Details
Date Symptoms First Started
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Medical Visit or Emergency Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Care Setting
*
Emergency Room
Urgent Care
Hospital Admission
Primary Care
Telehealth
Other
Provider or Facility Name
*
Short Description of What Happened
*
Records and Claim Authorization
Consent to review claim details and contact me about this matter
*
1
I agree
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