__[Attorney name]__ __[Address]__ __[Telephone number]__ Attorney for Plaintiff __[name]__ _ _ _ _ _ _ Court, County of _ _ _ _ _ _ __[_ _ _ _ _ _ District]__ _ _ _ _ _ _ _ _ _ _ _ _ _ ) No. _ _ _ _ _ _ Plaintiff(s)) vs. )NOTICE OF INTENTION TO )COMMENCE ACTION _ _ _ _ _ _ _ _ _ _ _ _ _ ) Defendant(s)) _________________________ ) To __[name of health care provider]__: PLEASE TAKE NOTICE that __[name(s) of plaintiff(s)]__ intend(s) to commence an action against you as a defendant, based on your professional negligence, 90 or more days from the date of this notice. The action will be based on allegations that you and other defendants negligently diagnosed and treated __[name(s) of plaintiff(s) or decedent]__, causing bodily injury __[and death]__. [Specify for each injured plaintiff] At the present time, the injuries to __[name of plaintiff]__ include: __[Specify nature of injuries]__. Detriment and loss sustained by __[name of plaintiff]__ include: 1. Medical and related expenses __[in the amount of $_ _ _ _ _ _/in an amount over $_ _ _ _ _ _/in an amount not yet fully ascertained]__ __[plus expenses reasonably certain to be incurred in the future]__. 2. Impairment of earning capacity __[in the amount of $_ _ _ _ _ _/in an amount over $_ _ _ _ _ _/in an amount not yet fully ascertained]__ __[plus loss reasonably certain to be incurred in the future]__. 3. Loss and expense of services __[in the amount of $_ _ _ _ _ _/in an amount over $_ _ _ _ _ _/in an amount not yet fully ascertained]__ __[plus loss reasonably certain to be incurred in the future]__. 4. Pain, suffering, emotional distress, and impairment of enjoyment of life. [Add if appropriate] 5. Detriment and loss sustained by __[name of plaintiff's spouse]__ include loss of consortium. [Add for each decedent] [6.] Detriment and loss sustained by __[names of decedent's heirs]__ include __[e.g., loss of financial support, services, contributions, gifts, society, comfort, companionship, care, training, and advice]__ from __[name of decedent]__, plus funeral and burial expense in the amount of $_ _ _ _ _ _. [Continue] Date: _ _ _ _ _ _ [Signature] _________________________ __[Typed name]__ Attorney for _ _ _ _ _ _ _ _ _ _
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Legal Forms : Set Two