Free IN THE ___________________ COURT - Tennessee

IN THE ___________________ COURT OF _____________________________ COUNTY, TENNESSEE

___________________________ Plaintiff, v. ___________________________ ___________________________ ___________________________ Defendant/s. NO. ________________ JURY DEMAND Judge ______________

CERTIFICATE OF GOOD FAITH
Medical Malpractice Case PLAINTIFF'S FORM

A. In accordance with T.C.A. § 29-26-122, I hereby state the following: (Check item 1 or 2 below and sign your name beneath the item you have checked, verifying the information you have checked. Failure to check item 1 or 2 and/or not signing item 1 or 2 will make this case subject to dismissal with prejudice.) G 1. The plaintiff or plaintiff's counsel has consulted with one (1) or more experts who have provided a signed written statement confirming that upon information and belief they: (A) Are competent under § 29-26-115 to express opinion(s) in the case; and (B) Believe, based on the information available from the medical records concerning the care and treatment of the Plaintiff for the incident(s) at issue, that there is a good faith basis to maintain the

action consistent with the requirements of § 29-26-115.

____________________________________________ Signature of Plaintiff if not represented, or Signature of Plaintiff's Counsel or G 2. The Plaintiff or Plaintiff's counsel has consulted with one (1) or more experts who have provided a signed written statement confirming that upon information and belief they: (A) Are competent under § 29-26-115 to express opinion(s) in the case; and (B) Believe, based on the information available from the medical records reviewed concerning the care and treatment of the Plaintiff for the incident(s) at issue and, as appropriate, information from the Plaintiff or others with knowledge of the incident(s) at issue, that there are facts material to the resolution of the case that cannot be reasonably ascertained from the medical records or information reasonably available to the Plaintiff or Plaintiff's counsel; and that despite the absence of this information there is a good faith basis for maintaining the action as to each Defendant consistent with the requirements of § 29-26-115 . Refusal of the defendant to release the medical records in a timely fashion, or where it is impossible for the plaintiff to obtain the medical records shall waive the requirement that the expert review the medical records prior to expert certification.

_________________________________________________ Signature of Plaintiff if not represented, or Signature of Plaintiff's Counsel

B.

You MUST complete the information below and sign:

I have been found in violation of T.C.A. § 29-26-122 _______ prior times. (Insert number of prior violations by you.)

________________________________________ Signature of Person Executing This Document

___________________ Date