Free IN THE ___________________ COURT - Tennessee

IN THE ___________________ COURT OF _____________________________TENNESSEE

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

CERTIFICATE OF GOOD FAITH
Medical Malpractice Case DEFENDANT'S FORM ALLEGATIONS OF FAULT AS TO NON-PARTY

(If a defendant has alleged in an answer or amended answer that a non-party is at fault for the injuries or death of the plaintiff, this form must be completed by the defendant or defendant's counsel making such allegation.) A. In accordance with T.C.A. Section 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 such allegations of fault of a non-party subject to being stricken with prejudice.) G 1. I have consulted with one (1) or more experts, which may include the defendant filing the Certificate of Good Faith, 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 reviewed concerning the care and treatment of the plaintiff for the incident(s) at issue, that there is a good faith basis to allege such fault against another consistent with the requirements of § 29-26-115.

____________________________________________ Signature of Defendant if not represented, or Signature of Defendant's Counsel

G

2.

I have consulted with one or more medical experts, which may include the defendant filing the Certificate of Good Faith, who have provided a signed written statement confirming that upon information and belief they: (A) (B) Are competent under § 29-26-115 to express opinion(s) in the case; and Believe based on the information reviewed concerning the care and treatment of the plaintiff for the incident(s) at issue, that there are facts material to the resolution of the case that cannot be reasonably ascertained from the information reasonably available to the defendant or defendant's counsel; and that despite the absence of this information there is a good faith basis for alleging such fault against another, whether already a party to the action or not, consistent with the requirements of § 29-26-115 . ____________________________________________ Signature of Defendant if not represented, or Signature of Defendant's Counsel

B.

You MUST complete the information below and sign:

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

__________________________________________ Signature of Person Executing This Document

_______________________ Date