National Assistance Screening Form

Question 1

What best describes the help you need?

Possible medical malpracticeSerious injury, delayed diagnosis, treatment error, surgery, medication issue, or death. Current patient-safety concernUnsafe discharge, treatment interruption, neglect, or immediate risk happening now. Attorney declined / cannot find representationI need to understand other possible paths. Nursing home, SNF, or unsafe dischargeResident rights, neglect, transfer, discharge, or placement concern. Complaint against provider or facilityI want to know where or how to report a concern. Medicare, Medicaid, or insurance problemCoverage ending, denial, appeal, or benefits concern. General advocacy guidanceRecords, timeline, evidence, attorney preparation, or patient-rights information.

Question 2

Where did the medical care or incident occur?

Choose the state where the care occurred, not necessarily where you live.

State or District of Columbia

Question 3

About when did it happen?

Important: NMMAA cannot determine whether a statute of limitations has expired. Legal deadlines vary by state and circumstances.

Question 4

What was the most serious outcome?

Death Permanent or life-changing injury Hospitalization, surgery, or major additional treatment Ongoing symptoms or treatment Concern or poor experience without major injury identified Not sure yet

Question 5

Is there a current safety problem happening now?

Yes — something is happening nowExamples: unsafe discharge, treatment stopped, serious neglect, or inability to safely care for the patient. No — this concerns a past event I am not sure

Question 6

Has an attorney already reviewed the matter?

No Yes — one or more attorneys declined Yes — an attorney is still reviewing it Yes — I already have legal counsel

Question 7

What kind of help are you looking for?

Choose the one that matters most right now.

Help finding legal review Help with a current patient-safety problem Help understanding where to file a complaint My case was declined — what can I do next? Help preparing records, timeline, or attorney consultation I mainly need information/resources

Optional

Would a short general summary help explain the issue?

This is optional. Keep it general. Do not include names, medical record numbers, Social Security numbers, insurance IDs, or detailed medical records.

0/600

This screening does not create an attorney-client relationship. NMMAA is not a law firm and does not determine whether malpractice occurred or whether a legal deadline has expired.

A short screening form — not a medical-record intake.