"Certificate of Good Faith in Medical Malpractice Case - Plaintiff's Form" - Tennessee

Certificate of Good Faith in Medical Malpractice Case - Plaintiff's Form is a legal document that was released by the Tennessee State Courts - a government authority operating within Tennessee.

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Download "Certificate of Good Faith in Medical Malpractice Case - Plaintiff's Form" - Tennessee

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IN THE ___________________ COURT
OF _____________________________ COUNTY, TENNESSEE
___________________________
Plaintiff,
NO. ________________
v.
JURY DEMAND
___________________________
Judge ______________
___________________________
___________________________
Defendant/s.
CERTIFICATE OF GOOD FAITH
Medical Malpractice Case
PLAINTIFF’S FORM
A.
In accordance with T.C.A. § 29-26-122, I hereby state the following: (Check item
1 or 2 below and sign your name beneath the item you have checked, verifying the
information you have checked. Failure to check item 1 or 2 and/or not signing item 1 or
2 will make this case subject to dismissal with prejudice.)
The plaintiff or plaintiff’s counsel has consulted with one (1) or more
G
1.
experts who have provided a signed written statement confirming that upon
information and belief they:
(A)
Are competent under § 29-26-115 to express opinion(s) in the
case; and
(B)
Believe, based on the information available from the medical
records concerning the care and treatment of the Plaintiff for the
incident(s) at issue, that there is a good faith basis to maintain the
IN THE ___________________ COURT
OF _____________________________ COUNTY, TENNESSEE
___________________________
Plaintiff,
NO. ________________
v.
JURY DEMAND
___________________________
Judge ______________
___________________________
___________________________
Defendant/s.
CERTIFICATE OF GOOD FAITH
Medical Malpractice Case
PLAINTIFF’S FORM
A.
In accordance with T.C.A. § 29-26-122, I hereby state the following: (Check item
1 or 2 below and sign your name beneath the item you have checked, verifying the
information you have checked. Failure to check item 1 or 2 and/or not signing item 1 or
2 will make this case subject to dismissal with prejudice.)
The plaintiff or plaintiff’s counsel has consulted with one (1) or more
G
1.
experts who have provided a signed written statement confirming that upon
information and belief they:
(A)
Are competent under § 29-26-115 to express opinion(s) in the
case; and
(B)
Believe, based on the information available from the medical
records concerning the care and treatment of the Plaintiff for the
incident(s) at issue, that there is a good faith basis to maintain the
action consistent with the requirements of § 29-26-115.
____________________________________________
Signature of Plaintiff if not represented, or Signature
of Plaintiff’s Counsel
or
The Plaintiff or Plaintiff’s counsel has consulted with one (1) or more
G
2.
experts who have provided a signed written statement confirming that upon
information and belief they:
(A)
Are competent under § 29-26-115 to express opinion(s) in the
case; and
(B)
Believe, based on the information available from the medical
records reviewed concerning the care and treatment of the
Plaintiff for the incident(s) at issue and, as appropriate,
information from the Plaintiff or others with knowledge of the
incident(s) at issue, that there are facts material to the
resolution of the case that cannot be reasonably ascertained
from the medical records or information reasonably available
to the Plaintiff or Plaintiff’s counsel; and that despite the
absence of this information there is a good faith basis for
maintaining the action as to each Defendant consistent with
the requirements of § 29-26-115 . Refusal of the defendant to
release the medical records in a timely fashion, or where it is
impossible for the plaintiff to obtain the medical records shall
waive the requirement that the expert review the medical
records prior to expert certification.
_________________________________________________
Signature of Plaintiff if not represented, or Signature of
Plaintiff’s Counsel
B.
You MUST complete the information below and sign:
I have been found in violation of T.C.A. § 29-26-122 _______ prior times. (Insert
number of prior violations by you.)
________________________________________
___________________
Signature of Person Executing This Document
Date
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