PA-C, RN or Clinician/Aesthetician - Patient Arbitration Agreement
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 incompletely rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California 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.
All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of it relate to treatment or services provided by the PA-C, RN or clinician/aesthetician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence given rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the clinician, and the PA-C, RN or clinician/aesthetician partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
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 30 days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within 30 days thereafter. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit.
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which 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
General Provisions: 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 California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein expressly provided for, the arbitration shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Supplemental Agreement by Responsible Person on Behalf of Minor, Unborn Child, or Disabled Person: I am the patient of, or legal guardian of, the patient and have read and understood the attached Arbitration Agreement between Alvarado Institute of Skin Care, Skin Care Enterprises and/or Alvarado Institute of Skin Care Inc. and the patient, including the first article and the NOTICE.
On behalf of the patient, I agree to bind the patient to the attached Arbitration Agreement.
If the patient continues to be unable to exercise his or her rights for thirty (30) days from the date of this Agreement, then my decision whether or not to revoke this Agreement shall bind the patient. I understand that the decision to revoke this Agreement, whether made by me or by the patient, shall be made by written notification thereof to the physician within these thirty (30) days.
Revocation: This agreement may be revoked by written notice delivered to the physician within thirty (30) days of signature and if not revoked will govern all medical services received by the patient.
Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
Effective as of the date of first medical services. ___________
Patient’s
or Patient’s Representative’s Initials
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 I OF THIS CONTRACT.”
_______________________________ ________________________________
Clinician’s or Duly Authorized Patient’s Signature DATE
Representative’s Signature
Alvarado Institute of Skin Care,
Skin Care Enterprises
Alvarado Institute of Skin Care, Inc.
_______________________________ _________________________________
Print or Stamp Name of Clinician, Print Patient’s Name
Medical Group or Association Name
_______________________________ _________________________________
Signature of Translator (if applicable) Patient’s Representative’s Signature
_______________________________ __________________________________
Print Name of Translator Print Name and Relationship to Patient