RELEASE ALLEGED MALPRACTICE CLAIMS
Release executed by ______________________________________________ (name), of __________________________________________________________ (address), as releasor, to ______________________________________ (physician), a physician duly licensed to practice medicine in the State of ____________________, maintaining an office at __________________________________________________ (address), as releasee.
In consideration of the sum of ___________ Dollars ($__________), receipt of which is hereby acknowledged, and in further consideration of ____________________ (the release by ___________________________________ (physician) of all claims for the value of all professional services rendered to me in the past or as the case may be), releasor releases ______________________________________ (physician) from all claims of whatever nature, known or unknown, including, without limitation, claims for personal injury and disability, pain, suffering, and mental anguish, and loss of income arising from: __________________________________________________________ ____________________________________________ (the treatment of and surgery in connection with ___________________ (illness or condition), which treatment and surgery commenced on ________________________ (month & day), _________ (year), and was concluded on ______________________ (month & day), __________ (year), and the following complications that subsequently developed: ______________ ______________________________________________________________________ ____________________________________________________________(enumerate), which complications were allegedly caused by the negligence of __________________ (physician) or as the case may be).
This release shall bind me, __________________________________________ (name of releasor), (or _______________________________________________ (name), my spouse,) and my heirs, legal representatives and assigns. It shall inure to the benefit of ______________________ (physician), and to _______________________________ (physician’s) heirs, legal representatives, successors and assigns. The coverage of this release is also intended to, and shall, extend to _______________________________ (physician’s insurer), the liability insurer of __________________________________ (physician), and its successors and assigns, (add, if appropriate: and to _____________ _____________________________ (name of hospital), located at _________________ __________________________________________ (address), the hospital at which the above-mentioned treatment and surgery took place, and its officers, agents, employees and liability insurance carriers).
I have read this release, understand the terms used in it and their legal significance, and have executed it voluntarily.
In witness whereof, releasor executes this release at ___________________ (designate lace of execution) on ________________________ (month & day) __________ (year).
______________________________ (Signature)
____________________ (Date)
(Attach statement of attorney, if desired.)