MMPPA Patient Protection Intake Form

Personal Information

Medical Information

MMPPA Violation Details

• Inadequate post-surgical pain management
• Revision surgery required due to surgical negligence
• Development of opioid use disorder post-surgery
• Extended opioid prescriptions without proper monitoring
• Healthcare provider ignored formal pain complaints
• Institution failed to report required data to Registry
• Insurance denied proper pain management coverage
• Retaliation for reporting MMPPA violations

MMPPA Services Requested

• National Registry Reporting Support
• Patient Pain Management Bill of Rights Education
• Whistleblower Protection Services
• Private Right of Action Support
• Accountability Mechanism Advocacy
• Institutional Compliance Reporting
• Insurer Accountability Support
• Pain Mismanagement Documentation
• Federal Oversight Coordination

Document Upload

Upload Supporting Documents

Recommended Documents:

• Complete medical records from surgery and follow-up appointments
• Surgical reports and operative notes
• Pain assessment records and patient complaints
• Opioid prescription records and pharmacy documentation
• Insurance correspondence and coverage decisions
• Any previous complaints filed with healthcare providers
• Documentation of complications or revision surgeries
• Evidence of reporting attempts or retaliation

Urgency Assessment

• Emergency: Immediate danger to health/safety requiring urgent intervention
• High Priority: Active opioid addiction or ongoing medical negligence
• Standard: Documentation and advocacy for resolved or past incidents

Contact Preferences

• Email communications preferred
• Phone consultations acceptable
• Secure messaging through patient portal
• Written correspondence by mail

Consent and Authorization

• I consent to the Resilience Project reviewing my case and providing MMPPA-based patient protection services. I understand all services are provided free of charge through philanthropic funding.

• I authorize the sharing of my case information with relevant federal agencies, medical boards, and legal authorities as necessary for MMPPA enforcement and accountability.

• I understand that case information will be processed confidentially through secure systems with HIPAA-compliant privacy protection.

• I consent to my de-identified case information being used for MMPPA advocacy, policy development, and healthcare reform efforts.