Doctor-Patient Arbitration Agreement

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									Doctor-Patient Arbitration
Agreement
This Doctor-Patient Arbitration Agreement can be used by a doctor, physician, or any
medical offices that offer medical services to patients to ensure that any dispute will be
submitted to binding arbitration. Arbitration is a popular form of alternative dispute
resolution that can be more expeditious and cost-effective than the traditional court
system. The doctor can simply fill out their information and this agreement will be ready
for distribution to incoming patients. This agreement is ideal for small businesses that
offer medical services and want to arbitrate claims instead of resorting to the traditional
court system.
                  DOCTOR-PATIENT ARBITRATION AGREEMENT

THIS DOCTOR-PATIENT ARBITRATION AGREEMENT (hereinafter referred to as the
“Arbitration Agreement”) is hereby made and entered into by and between
_________________________ [Instructions: Insert the Doctor’s name] (hereinafter referred to
as the “Doctor”), of _______________________________________ [Instructions: Insert the
Doctor’s address] and the Patient (hereinafter referred to as the “Patient”).

WHEREAS, Doctor and Patient entered into a medical services agreement (the “Agreement”)
with respect to Doctor’s providing of medical care to Patient; and

WHEREAS, the parties agree that the terms of this Arbitration Agreement are integral to Doctor
providing medical services pursuant to the Agreement, and desire to clarify the each party’s
rights and remedies with respect to the Agreement with the terms of this Arbitration Agreement.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth
below, it is hereby covenanted and agreed by the parties as follows:

1.       ARBITRATION

It is understood that any dispute as to medical malpractice, that is as to whether any medical
services rendered under the Agreement were unnecessary or unauthorized or were improperly,
negligently or incompetently rendered, will be determined by submission to binding arbitration
as provided by __________________ [Instructions: Insert the state’s laws that will govern
the arbitration] law, and not by a lawsuit or resort to court process except as
____________________ [Instructions: Insert the state’s laws that will govern the
arbitration] law provides for judicial review of arbitration proceedings. Both parties to this
Arbitration Agreement, 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.

2.       ARBITRATION RULES

Arbitration will be in accordance with the current Medical Arbitration Rules of the
_________________ [Instructions: Insert the state’s laws that will govern the arbitration]
Medical Association. Copies of those rules are available at the Doctor’s office.

3.       APPLICABILITY TO CLAIMS AND ACTIONS

This Arbitration Agreement applies to any legal claim or civil action in connection with the
medical services provided pursuant to the Agreement, including, but not limited to, disputes as to
medical malpractice, against Doctor, Doctor’s practice, the hospital or facility where Doctor’s
practice is located, and/or Doctor’s employees.

4.       RESCISSION OF AGREEMENT




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The execution of this Arbitration Agreement is not a pre-condition to the furnishing of medical
services by Doctor. This Arbitration Agreement may be rescinded by written notice from the
Patient or Patient's representative to the Doctor within __________ (___) [Instructions: Insert
the number of days] days of Patient’s execution hereof.

5.       MISCELLANEOUS

       a.      This Arbitration Agreement constitutes the entire agreement between the parties
hereto with respect to the specific subject matter hereof and supersedes all prior agreements or
understandings of any kind with respect to the specific subject matter hereof.

        b.     In the event that any provision or part of this Arbitration Agreement shall be
deemed void or invalid by a court of competent jurisdiction, the remaining provisions or parts
shall be and remain in full force and effect.

       c.      Any and all additions, deletions, or modification to this Arbitration Agreement
must be in writing and signed by the parties or it shall have no effect and shall be void.

        d.     This Arbitration Agreement is binding upon and shall inure to the benefit of the
respective successors, licensees and/or assigns of the parties hereto.

       e.     This Arbitration Agreement shall be governed in accordance with the laws of the
State of _________________ [Instructions: Insert the state’s laws that will govern this
agreement] applicable to agreements to be wholly performed therein, without giving effect to its
laws governing conflict of laws.

6.       NOTICE

BY SIGNING THIS ARBITRATION AGREEMENT YOU ARE AGREEING TO HAVE ANY
ISSUE OF MEDICAL MALPRACTICE DECIDED BY BINDING ARBITRATION AND
YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE PARAGRAPH
1 OF THIS ARBITRATION AGREEMENT.

I hereby agree to submit any and all claims that may arise from the medical services rendered by
Doctor or Doctor’s employees to binding arbitration.

Patient’s Name: _________________________________

Patient’s Signature: _______________________________

Date: ___________________________________




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