Federal Indian Hospitals

Federal Indian Hospitals - Intake Form

THIS IS NOT A CLAIM FORM
Have you already filed a claim?
Name

First NameLast Name
Birthday

MonthDayYear
Date
Please include your contact information, or we will NOT be able to contact you.
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityProvince

Postal
Which one do you identify as?
If applicable, what First Nation are you from?
Which Hospital Did You Stay at?

If you stayed at multiple Hospitals please add in the "Other" box. If the Hospital is NOT listed, there is a chance that it is NOT eligible, however please add to the "Other" Box.
British Columbia
Alberta
Saskatchewan
Manitoba
Ontario
New Brunswick
Territories
If Other, explain:
When were you admitted at a Federal Indian Hospital? (years and ages)
How long did you stay in a Federal Indian Hospital?
How many Days, Weeks, Months, or Years (approximately)
Why were you admitted at a Federal Indian Hospital?
Did you experience abuse while admitted at Federal Indian Hospital?
If yes, what kind of abuse did you experience?
You may be eligible for compensation for psychological, verbal, physical, and/or sexual abuse that you experienced while admitted at a Federal Indian Hospital (FIH), within the eligible years (1936 to 1981), dates vary at each FIH.

The Settlement Agreement excludes compensation for any claim connected to medical treatment (i.e. medical malpractice) at Federal Indian Hospitals.

You are likely NOT eligible for being born in a FIH or having poor medical treatment in a FIH.
If you are able to give us more details about your experience, please do. (All details will be kept between you and the law firm)
Should be Empty:

Federal Indian Hospitals - Intake Form

Which Hospital Did You Stay at?