Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical
services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered,
will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process
except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into
it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting
the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice,
including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding
arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or
relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the
patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient
whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and
the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the
patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working
at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or
the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated
including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party
shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the
arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall
decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral
arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees,
witness fees, or other expenses incurred by a party for such party’s own benefit.
Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper
additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or
entity shall be stayed pending arbitration.
The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any
amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic
losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this
Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association
shall govern any arbitration conducted pursuant to this Arbitration Agreement.
Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated
in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a
civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in
accordance with the procedures prescribed herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of
signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for
example, emergency treatment) patient should initial here. _______. Effective as the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and
shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration
Agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF
MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING
UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
(Or Patient Representative) (Indicate relationship if signing for patient)