ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any and all disputes between the “Signer” (patient, client, customer, vendor, family members, friends or any other entities), and the “Provider” (Dr. Kiup Alex Kim, Bellagio Clinic, Advanced Minimally Invasive Surgical, any other associated entities, and their employees, staffs, and agents), will be determined by submission to arbitration as provided by Federal Arbitration Act law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. In particular, dispute regarding medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, out of standard of care, or incompletely rendered, will also be arbitrated. Also, loss of chance, potential future problems, or civil rights violation claims will also be arbitrated. Both parties to this contract, the Signer and the Provider, 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. 

INITIAL IF READ AND UNDERSTOOD: ___________

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties including the office or medical facility, including any past, present, or future spouse(s) or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for the loss of consortium, wrongful death, emotional distress or punitive damages. 

INITIAL IF READ AND UNDERSTOOD: ___________

Article 3: 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 thirty days, and a third abitrator (neutral arbitrator) shall be selected from a court-approved list by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party's own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that 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 the Federal Arbitration Act shall apply to disputes within this arbitration agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. 

INITIAL IF READ AND UNDERSTOOD: ___________

Article 4: General Provision: 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 legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. 

INITIAL IF READ AND UNDERSTOOD: ___________

Article 5: Attestation: The “Signer” is not in need of emergency care or under immediate stress at the time of signing this document. Enough time and explanation have been given, and the “Signer” has no further questions about this Agreement. This Agreement is not a condition of treatment or service, and the “Signer” will still be treated even if he or she does not sign the agreement.

INITIAL IF READ AND UNDERSTOOD: ___________

Article 6: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 15 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties. Additionally, before signing the Agreement, the Patient may make written changes in the Arbitration Agreement if they so desire and present these to the Clinic for approval.

INITIAL IF READ AND UNDERSTOOD: ___________

Article 7: Retroactive Effect: This agreement will also cover services rendered before the date it is signed (for example, emergency treatment), and is effective as the date of first professional services, contact, exchange, establishment of physician-patient relationship.  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. 

INITIAL IF READ AND UNDERSTOOD: ___________

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 1 OF THIS CONTRACT.

PATIENT or Patient Representative's Signature  _________________________________________________         

   

Print Name _____________________________________________   DOB ____________   Date/Time __________________

          

By signing below, the officer confirms that a thorough and detailed explanation of this Arbitration Agreement was given, and patient received ample time to ask questions and receive answers, as well as a copy of this Agreement.  

STAFF Signature ______________________________________    Date/Time ____________________    Copy Given ______


RECEIPT OF ARBITRATION AGREEMENT

The patient and related family members, by signing below, attest that they have been given enough time to ask questions and receive answers regarding the Arbitration Agreement, and that they have received a copy of the Agreement.

“SIGNER”, PATIENT or Patient Representative's Signature  _________________________________________________________                

Print Name ____________________________________________   DOB ____________   Date/Time __________________