Pennsylvania Code
Title 37 - LAW
Part III - Agencies and Offices
Subpart H - Arbitration Panels for Health Care
Chapter 171 - RULES OF PRACTICE AND PROCEDURE
FORMS
Section 171.152 - Form for notice complaint
The following is the form for notice complaint
COMMONWEALTH OF
PENNSYLVANIA
ARBITRATION PANELS FOR
HEALTH CARE
|
vs. |
: |
No. |
|
County: |
NOTICE COMPLAINT
TO:___________________
Name of Defendant(s)
You are hereby notified that the Plaintiff(s)___________ allege(s) that the Defendant(s)___________ (has)(have) committed a tort or breach of contract causing injury or death to__________ resulting from the furnishing of medical services which were or which should have been provided.
Wherefore, plaintiff(s) request(s) arbitration of this claim under the Health Care Services Malpractice Act, 40 P. S. § 1301.101 et seq., and judgment in (his)(her) (their) favor.
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___________ |
By: ___________ |
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Date |
Attorney for Plaintiffs |
This section cited in 37 Pa. Code § 171.23 (relating to commencement of proceedings).
