37 Pa. Code § 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.

___________	By: ___________
Date	Attorney for Plaintiffs

Notes

37 Pa. Code § 171.152

This section cited in 37 Pa. Code § 171.23 (relating to commencement of proceedings).