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Lost Wages Form for Medical Malpractice Case

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DATE ____________________


This wage and bonus loss form is for the benefit of your employee in his or her claim arising out of an instance of medical malpractice that in no way arose in connection with his or her employment with your company. It will be to your employee's advantage if this form is filled out completely.

Employer name: __________________________

Company address: __________________________

Name of employee: __________________________

Social security no. : __________________________

Telephone: __________________________

Date employed: __________________________

Time lost from work : from __________________ to _________________

Salary: $ ______________ per ______________

Hours worked per week: ___________________________________________

Bonus, commission or overtime lost, if any : $___________________

Employee’s regular duties:


Signed ________________________________

Official title ________________________

Telephone ___________________________

I hereby authorize my employers to release the requested wage and bonus information to my attorneys:


Employee signature: ______________________________________

Date: ______________________________________

Recovering Lost Wages in a Medical Malpractice Lawsuit

The amount of lost wages you can receive in a medical malpractice case will be based on the severity of your injury, how much you lost from time away from work, and reimbursement for any missed work opportunity now that you are suffering a temporary or permanent disability. Under civil tort law, you are entitled to be reimbursed from any individual who was legally responsible for causing your injuries. Potential defendants in your lawsuit could include the doctor, surgeon, hospital, medical center, nurse, or other healthcare provider.

The amount of compensation you may receive could include your salary or wages from a part-time or full-time job, or funds you would have generated from occasional or regular employment. Even those who are self-employed can receive salary reimbursement from all defendants involved in their medical malpractice lawsuit. Even vacation pay and sick leave can be reimbursed if you miss time away from work due to your injuries caused by the negligent actions of others.

By law, you were entitled to receive that vacation time or sick leave through your employer whenever it was wanted or needed. However, to receive reimbursement, you must prove two elements of your case that include:

  • You missed time away from work because of the event caused by medical malpractice, and
  • The money you demand would have been the wages or salaries you would have earned during the time you were unable to work because of your injuries.

Document Your Lost Income

If you worked a regular job before you were injured through medical malpractice, you need to collect information concerning the amount of income you lost. The only documented evidence of your lost income is obtained through your personnel office, boss, or supervisor. The information should be documented in written form on a piece of paper that contains the company logo were letterhead. Your employer writing the letter should ensure the document contained your name, rate of pay, position with the company, and the number of hours you typically worked for wages or your weekly salary. Make sure your employer documents how many days or hours you missed because you were injured.

Documenting how much income you have lost can be significantly more complicated if your typical work schedule was irregular or you were self-employed before the incident occurred. You will need to document the time you lost for the earnings you likely would have generated had you been able to work. Include any other evidence that might help identify how much you would have earned that might be recorded on invoices, billing, or any calendar documenting the appointments that were canceled after your injury. Document any appointment that you could not attend because of medical malpractice.

In addition to providing documented evidence about how much work was missed due to your injuries, record the amount of earnings you likely would have generated had you not taken time off from work. You can average the amount of earnings you might have generated by using payments received, invoices, billing, or another form of evidence that you earned money routinely. Afterward, calculate the amount of income you believe you lost in the time you are were unable to continue working.

If your work schedule was sporadic, then calculate how much earnings you lost over several months or weeks. Be accurate and show the weeks that you generated lots of income as well as the weeks when you generated little or none. Average out the total amounts of every week over the course of a few months or more to determine what you should have made if you would not been injured.

Your annual tax records can provide ample evidence of what you generate each year. However, you will only need to provide evidence that shows your annual gross income. Any exemption, deduction, or credit you would receive on your tax records is irrelevant. Additionally, your lawyer will advise you that the insurance carrier does not have a right to view any more of your records than is necessary to prove your earnings. If during the year before the accident occurred you generated low earnings, average out two or three years of tax returns to provide an accurate record of what you typically make.

Document Every Lost Opportunity

You might have lost more earnings than the amount of your wages or salary would have generated at work. You may be entitled to receive financial reimbursement for any lost work opportunity because you were injured through medical malpractice. While it might be challenging to prove that you lost the opportunity for a new job because you missed your job interview due to your injuries, your attorney will still need to see that documentation to help maximize your reimbursement.

It may be difficult to pinpoint the specific dollar amount that was lost from your missed job opportunity. However, presenting the evidence to the claims adjuster can show the potential lost income you had to ensure you receive maximum compensation.

The Basis of Most Medical Malpractice Claims

The personal injury attorneys at Rosenfeld Injury Lawyers LLC have represented many clients who were injured through medical malpractice, or a doctor, nurse, or hospital which was medically negligent. Many of the cases we have handled involve:

  • A misdiagnosis, failure to diagnose, or delay in diagnosing a medical condition,
  • Performing an unnecessary surgical procedure,
  • Ignoring or mistreating lab test results
  • Performing surgery at the wrong site
  • Making a surgical mistake
  • Giving a patient the wrong medication, wrong dosage, or wrong instructions,
  • Discharging the patient prematurely
  • Not ordering necessary tests
  • Not recognizing common symptoms associated with the patient's condition
  • Providing substandard aftercare

Calculating Damages Formula

Once you have proven that the doctor, medical professional, or hospital was legally liable for your injuries, your attorney can calculate how much you are entitled to receive for your compensation. Your lawyer might determine that you should receive reimbursement for:

  • Medical bills

  • Hospitalization costs

  • Funds for future rehabilitation, surgical procedures, and speech, occupational, and physical therapies

  • The costs associated with permanent physical disabilities and disfigurements

  • Reimbursement for missed time at work and loss of future earnings

  • Non-economic damages including pain, suffering, emotional trauma, and mental stress,

  • The loss of social and family experiences,

  • The loss of educational opportunities

  • Funeral expenses and burial costs associated with a wrongful death lawsuit when the victim died from a medical mistake

Using the Formula

When the negotiations begin on your claim for compensation, your attorney will typically add up all your expenses including medical bills, hospitalization costs, and the need for future treatment. These “special medical damages” do not include pain, suffering, emotional damage, or permanent disabilities that are usually referred to as “general damages.”

Typically, special damages are calculated at one and a half times to three times their amount in victims who are suffering from relatively minor injuries. This number typically increases to five times the amount of economic damages when the victim suffers particularly painful, severe injuries. Afterward, your lawyer will add the amount of income that was lost because you were injured through medical malpractice. Once this number is reached, the plaintiff and defendants can schedule a settlement negotiation meeting.

Usually, when the insurance company is negotiating a settlement with the plaintiff, the adjuster typically does not inform the victim how they formulated the worth of the claim. Instead, they protect that number to help negotiate what they want. For counterbalance, you and your attorney should keep the amount you have in mind secret from everyone, especially the insurance adjuster that is responsible for settling your case.

Were my Injuries the Result of Medical Malpractice?

According to State medical boards, medical malpractice can happen if a doctor, nurse, health care professional, hospital, or medical center acted negligently and caused the patient to become injured. Their negligent action might have occurred in making a misdiagnosis, failure to diagnose, or delay diagnoses, or not treating or managing the patient's care by acceptable standards.

Your attorney will determine that you have a valid medical malpractice claim if your case has one or more characteristics listed below. These include:

  • The hospital or medical professional violated the acceptable standard of care – The laws involving civil tort acknowledge that specific medical standards recognized by professionals must be used to provide medical treatment to patients. The standards are defined by what reasonably prudent health care medical professionals would provide under similar circumstances. Every patient maintains the right to expect that their doctor or healthcare professional will provide care consistent with accepted standards. Any violation of the standard of care could result in medical malpractice.

  • Medical Negligence Caused the Injury – To validate a medical malpractice claim for compensation, the victim must prove more than that the doctor or healthcare professional violated the standard of care. The victim must show that they would not have been injured had medical negligence not occurred. This means that having an undesirable outcome after treatment, surgical procedure, or diagnosis might not be malpractice on its own. The victim is required to prove that someone or some company's negligence resulted in their injury. Without negligence that led to the injury, the victim has no case.

  • The Victim's Damages Are Significant and Real – Conducting a medical malpractice claim for compensation can be very expensive during the litigation process. To successfully resolve the case, your attorney will rely on the testimony of many medical experts obtained through numerous depositions. To validate the case, your attorney will need to prove that your significant damages are the result of the injury you received because someone was medically negligent.

If your injuries are minor, you may not be able to receive an amount of compensation to recover the substantial cost of pursuing a claim for monetary recovery. The amount you are owed to reimbursement will need to cover temporary or permanent disabilities, unusual pain, loss of income (past and future), hardship, suffering, and the financial burden associated with all future medical expenses.

Hiring an Attorney is Necessary

The medical malpractice injury attorneys at Rosenfeld Injury Lawyers LLC understand that the harm you receive was not your fault but was caused by medical negligence. Our team of attorneys have successfully obtained millions on behalf of the victims and their family members to ensure they were adequately compensated to cover their medical expenses, household bills, lost wages, loss of future earnings, pain, suffering, and emotional damage and we can help your family too.

Our law firm encourages you to contact our attorneys today to schedule a no-obligation case consultation to discuss the merits of your monetary recovery claim without charge to you or your family. We accept all personal injury cases, wrongful death lawsuits, and medical malpractice injury claims through contingency fee arrangements. This legal contract postpones the payment of legal services until after we have successfully completed your case through a negotiated settlement or a jury verdict.

Our law firm gets results quickly because we understand you need money now. We proudly offer every client a “No Win/No-Fee” Guarantee, meaning if we are unable to secure financial compensation on your behalf you owe us nothing. All information you share with our law office will stay confidential.

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Jonathan Rosenfeld was professionally objective, timely, and knowledgeable. Also, his advice was extremely effective regarding my case. In addition, Jonathan was understanding and patient pertaining to any of my questions or concerns. I was very happy with the end result and I highly recommend Jonathan Rosenfeld. Michonne Proulx
Extremely impressed with this law firm. They took control of a bad motorcycle crash that left my uncle seriously injured. Without any guarantee of a financial recovery, they went out and hired accident investigators and engineers to help prove how the accident happened. I am grateful that they worked on a contingency fee basis as there was no way we could have paid for these services on our own. Ethan Armstrong
This lawyer really helped me get compensation for my motorcycle accident case. I know there is no way that I could have gotten anywhere near the amount that Mr. Rosenfeld was able to get to settle my case. Thank you. Daniel Kaim
Jonathan helped my family heal and get compensation after our child was suffered a life threatening injury at daycare. He was sympathetic and in constant contact with us letting us know all he knew every step of the way. We were so blessed to find Jonathan! Giulia
Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa