Medical Arbitration Agreement Form
Complete this form to record participant details, the arbitration agreement date, and the required acknowledgment for medical dispute arbitration. Do not include sensitive health information.
Participant Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Arbitration Agreement Details
Medical organization or practice name
*
Agreement date
*
-
Month
-
Day
Year
Date
Dispute resolution preference
*
Binding arbitration
Non-binding mediation first
Optional arbitration
Other
Acknowledgment of arbitration terms
*
Signature and Confirmation
Signer Name
*
First Name
Middle Name
Last Name
Signature
*
Submit
Submit
Should be Empty: