Medical Review Panel Request

Per R.S. 40:1231.8, a request for review of a malpractice claim or malpractice complaint shall contain, at a minimum, all of the following:

A request for the formation of a medical review panel.
The name of the patient.
The names of the claimants.
The names of the defendant health care providers.
The dates of the alleged malpractice.
A brief description of the alleged malpractice as to each named defendant health care provider.
A brief description of the alleged injuries.

1. Patient/Plaintiff Name (first, middle, and last)

2. Claimant/Plaintiff Name(s) (first, middle, and last, if different from patient or if patient is deceased and/or a minor)

3. Patient/Plaintiff Address

3.a Plaintiff Phone Number

3.b Plaintiff Email Address

4. Date(s) of Alleged Medical Malpractice

(Must include a month and year, and the date of death if the patient is deceased.)

5. Alleged Injury to Patient

Medical Review Panel Request

Patient Name

6. Name(s) of Defendant Health Care Providers AND alleged malpractice as to each

Must include first and last name, and any distinguishing prefix or suffix, for example Jr., Sr., II, or III.

Defendant Name and Allegations

Medical Review Panel Request

Patient Name

If additional space is needed for any of the above information, please save or print multiple copies of this form to accommodate necessary information.

Signature

(Filing Plaintiff)

Print Name

Date

Pursuant to Louisiana Revised Statute 40:1231.8.A(2)(a)(b), all requests for review of a malpractice claim and/or amendments adding defendants must be filed with the Commissioner of Administration.

The Act also states that filing a complaint with any agency other than the Commissioner of Administration shall not suspend or interrupt the running of prescription.

The Division of Administration

Medical Review Panel

P.O. Box 44336

Baton Rouge, LA 70804-4336

The Division of Administration

Medical Review Panel Claiborne Bldg

1201 North 3rd St. - 7th Floor, Suite 210

Baton Rouge, LA 70802

Fax: (225) 342-1057

Medical Review Panel