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Provider-Patient Voluntary Arbitration Agreement
I. Agreement to Arbitrate
e parties to this Provider-Patient Voluntary Arbitration Agreement (“Arbitration Agreement” )
are _________________________________________________ (insert name of physician)
and ________________________________________________ (insert name of medical group or entity providing
medical services), (collectively, the “Provider”) and the Patient named below. It is understood that any dispute as
to medical malpractice- that is as to whether any medical services rendered or that were failed to be rendered by
the Provider or by any of the Provider’s agents, employees, associates, sta members, partners, ocers, directors,
shareholders, proprietors or equity owners to the Patient were unnecessary or unauthorized, were improperly,
negligently, or incompletely rendered, or the failure to render such services were improper or otherwise negligent-
will be determined by submission to arbitration binding upon the parties and not by a lawsuit or other resort to
court or the judicial process except as state law provides for judicial review of arbitration proceedings.
e parties recognize that, in Missouri, there is a right to appeal an arbitration award; however, unless there is
evidence of fraud on the part of the arbitrator(s) or a serious procedural defect, an arbitration award pursuant to
this Arbitration Agreement would not be overturned and would be a nal award. e parties to this Arbitration
Agreement, by entering into it, are waiving their constitutional right to have any such dispute decided in a court of
law before a jury or before a judge and instead are accepting the use of arbitration as the appropriate and exclusive
forum to resolve any dispute or controversy between them.
II. All Claims Must be Arbitrated
It is the mutual agreement and intension of the parties that this Arbitration Agreement bind all parties whose claims
may arise out of or related to treatment or services provided by the Provider, including any spouse or heirs of the
Patient, or any others making claim on the Patient’s behalf, and any children, whether born or unborn at the time
of occurrence giving rise to any claim, including where a claim arises due to treatment of or services provided to
any pregnant women, e term “Patient” herein shall include that individual receiving medical treatment or advice
and, where applicable, shall include both the women patient and the women’s expected child or children. e term
“Provider” herein shall include all of the Provider’s agents, employees, associates, sta members, partners, ocers,
directors, shareholders, proprietors or equity owners.
e parties mutually agree that they shall submit to binding arbitration all disputes (except actions by the Provider
to collect fee) against each other and their respective agents, partners, associates, ocers, directors, shareholders,
equity owners, employees, representatives, members, duciaries, governing bodies, subsidiaries, parent companies,
aliates, insurers, attorneys, predecessors, estates, successors and assigns, or any of them and all persons,
corporations, partnerships or other entities with whom any of the former have been, are now or may be aliated
with at the time of the accrual of the cause of action, for all disputes arising out of or in any way related to or
connected with the care and treatment of the Patient provided by the Provider, including but not limited to any
disputes concerning alleged personal injury to the Patient caused by improper or inadequate care; allegations of
medical malpractice; claims of loss of consortium, wrongful death and emotional distress; any dispute concerning
whether any statutory provisions relating to the Patient’s rights under Missouri law were violated; any claim for
punitive damages; and any other dispute under Missouri or federal law based on contract, tort or statue, all of which
shall be determined by submission to binding arbitration and not by a lawsuit or resort to judicial process except as
state law provides for judicial review of arbitration proceeding. e ling of any action in any court by the Provider