Name____________________________________________________________________________
Home Address ____________________________________________________________________
City/State/Zip ____________________________________________________________________
Employer _________________________________________________________________________
Title/Occupation __________________________________________________________________
Business Address __________________________________________________________________
City/State/Zip _____________________________________________________________________
Work # ____________________________________ Home # _______________________________
E-Mail_____________________ Website_____________________ Fax # _____________________
1. Name of person who suffered from the medical experience/error, if other than
yourself: __________________________________________________________________________
Relationship to you ___________________________________________________________
2. Description or nature of the medical experience/error that occurred.
(Attach separate sheet, if necessary)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Was an HMO involved? ___ Yes ___ No
If so, give the name of the HMO_________________________________________________
4. Give name and location of the facility, and date the incident occurred.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. Attending physician or medical personnel at time medical experience/error
occurred.
__________________________________________________________________________
__________________________________________________________________________
6. Have you sought legal counsel regarding this experience to date? __ Yes
__ No
If yes, what attorney or law firm_________________________________________________
7. Briefly, explain the course of action you have taken so far.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8. Please indicate what service you desire of T.A.M.E.'s at this time.
__________________________________________________________________________
__________________________________________________________________________
AUTHORIZATION
Talk About Medical Experiences (T.A.M.E.)
I, _______________________________, (Client) hereby give my consent to have T.A.M.E. represent and assist me as a patient advocate organization regarding my medical experience. In addition, I also hereby authorize my medical records to be released to T.A.M.E.
Brief description of your experience (injury/mistake/etc.)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Date Occurred: _________________________________________________________________
__________________________________________
Client’s Name (please print)
____________________________________
Client’s Signature
____________________________________
T.A.M.E. Representative
____________________________________
Date