Fill and Sign the Malpractice Claim Form

Agreement to Arbitrate Malpractice Claim of Clinic Offering Neurointegration Therapy NOTICE: BY SIGNING THIS AGREEMENT TO HAVE ANY CLAIM OF MALPRACTICE DECIDED BY A PANEL OF THREE ARBITRATORS, YOU ARE WAIVING YOUR RIGHT TO A TRIAL BY JUDGE OR JURY. Agreement made on the __________________ (date) , between _________________________ (Name of Patient) of ___________________________________________________________________________________ (street address, city, county, state, zip code) , referred to herein as Patient , and _______________________________ (Name of Corporation) , a professional corporation organized and existing under the laws of the state of __________________, with its principal office located at ______________________________________________ ______________________________ (street address, city, county, state, zip code) , referred to herein as Clinic . Whereas, Clinic uses a Neurointegration in addressing and treating certain types of brain disregulation problems; this system combines EEG neurofeedback, photic stimulation, motion therapy, and auditory/visual programs; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: Patient and Clinic hereby agree to arbitrate any claim or dispute, except disputes over charges for services rendered and claims under ___________________ (dollar amount) , which may arise today or in the future out of, or in connection with, Clinic's program of treatment for Patient. Patient understands that he/she can choose trial by judge or jury or arbitration to resolve such a claim or dispute. However, Patient freely chooses arbitration, which Patient understands is a procedure by which a panel of three people, usually mutually chosen by the parties to a dispute, decide the facts and the law of the case rather than a judge or jury. Patient also understands and agrees that any arbitration will be conducted in accordance with Rules of the American Arbitration Association ( AAA ) which are incorporated by reference in this Agreement, and the arbitration shall be administered by the AAA. Patient further understands that he/she may have to pay his/her share of the expenses of arbitration up to a maximum of ___________________ ( dollar amount) . The undersigned further agree that the term Clinic includes the employees, officers, and directors, and the term Patient includes the heirs and assigns of Patient. The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of _____________________. Any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. The execution of this Agreement to arbitrate is not a requirement for health care. Patient or Patient's legal representative may revoke this arbitration agreement, up to (specify, such as: 30) _____ days after the Parties sign it by a letter to the Clinic. Patient certifies that he/she has read this agreement or has had it read to Patient, that he/she fully understand its contents, and execute this Agreement of his/her own free will. WITNESS our signatures as of the day and date first above stated. __________________________________________ (Name of Clinic) ______________________________ By: ______________________________ (P rinted Name of Patient) _________________________________ (P rinted name & Office in Corporation) ______________________________ _________________________________ (Signature of Patient) (Signature of Officer)