Medical Malpractice Settlement Reporting Worksheet

For Data Collection Only – All Reports Must be Submitted Online

Ed. 8/01/2008

Medical Malpractice Settlement Reporting Information
Claim information must be reported if a lawsuit is filed related to any medical malpractice claim. Please refer to:
  • RCW 48.140.010 subsection (1) for the definition of “claim” and subsection (9) for the definition of “medical malpractice.”
  • RCW 7.70.140(2)(a) for a description of the types of settlements that must be reported.
  • WAC 284-24E-063 for rules that explain when a claim must be reported.
  • WAC 284-24E-080 for rules that explain who has the primary responsibility to report claim data.
  • WAC 284-24E-050 for information about how your User ID is assigned.

Please provide information about the lawsuit.
On what date was the lawsuit filed? (See RCW 7.70.140 (2)(a)(iii))
On what date did the medical incident occur that led to the lawsuit? (see RCW 7.70.140(2)(b)(i))
In which county did the medical incident occur? (See RCW 7.70.140(2)(b)(ii))
What was the date of the final settlement?
Please provide information about the injured person.
What was the injured person's age on the date of medical incident?
The reporting application will request an age group. (see RCW 7.70.140(2)(b)(iv)). / Infant Yes No
Age:
What was the injured person's gender on the date of the medical incident? (see RCW 7.70.140(2)(b)(iv)): / Male Female Unknown
Please provide information about the outcome of this litigation.
Did a court, private trial, arbitration or other legal forum resolve the litigation in favor of the defendant(s), resulting in no indemnity payment to the plaintiff(s) (see RCW 7.70.140(2)(a)(iii)? / Yes (go Legal Expenses section)
No (complete all sections)
Settlement Information (Method of Claim Disposition)
What was the method of settlement? (Reference WAC 284-24E-110) / Disposition:
Settled by parties
Claim(s) disposed of by a court:
Directed verdict for plaintiff
Judgment notwithstanding verdict for defendant
Judgment for plaintiff
Judgment for plaintiff after appeal
Disposed by alternative dispute resolution (ADR) process:
Arbitration;
Mediation
Private trial
Other (describe ADR)
Other (describe)
What was the timing of the settlement? (Reference WAC 284-24E-120) / Before trial or alternative dispute resolution process
During trial or hearing
After trial/hearing, before judgment/award
After judgment/award, before appeal
During appeal
After appeal
Judgment, verdict, or award
How much was paid to all claimant(s) to settle this claim?
Please report the sum of all payments made by all defendants to settle all claims related to this incident of medical malpractice. You must report the gross amount of all indemnity payments made to resolve claim(s) related to the lawsuit. Please report all payments made from all defendant(s), including payments for derivative claims, rounded to the nearest dollar. (Reference RCW 7.70.140(2)(b)(v)(A),WAC284-24E-063, WAC 284-24E-130 and WAC 284-24E-140), WAC 284-24E-150.) / $
How much did all plaintiffs (claimants) pay for legal expenses?
Total legal fees paid to attorney(s), including contingency fees and all related billings for legal services (see RCW7.70.140(2)(b)(v)(B) and WAC 284-24E-150) / $
Total expenses paid for expert witnesses (see RCW 7.70.140(2)(b)(v)(C) and WAC 284-24E-150) / $
Total expenses for court costs, arbitration and/or mediation fees (see RCW 7.70.140(2)(b)(v)(D) and WAC 284-24E-150: / $
Any other legal expenses / $
Total legal expenses / Self Calculating Field

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Data entered into the OIC Reporting Site are confidential under RCW 42.56.400(10)