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Physician-Patient Contractual
Arbitration Agreements for California

If you would like to order additional contractual Arbitration Agreements, please complete and return the order form below.

If you have questions regarding contractual arbitration, please call (800) 421-2368, extension 1243.

You can also read an overview on physician-patient arbitration, “Resolving Disputes Through Contractual Arbitration,” view a sample of the agreement form, or download the following educational materials:

• Implementing Contractual Arbitration in Your Office
• Tips for Implementing Contractual Arbitration in California Practices 
• Frequently Asked Questions: Contractual Arbitration in California
• Understanding Contractual Arbitration in California

 

Policy Number:	Bold fields are required
Policy Name/Group:
Address:
City:
State:	CA (for California members)
Zip Code:
Language/Quantity	English    100 200 300 400 500 600 700 800 900 1000    Spanish   100 200 300 400 500 600 700 800 900 1000
Do all the physicians/allied health/midlevel practitioners request all patients to sign the form?
	Yes      No
Does any physician/allied health/midlevel practitioner tell patients they must sign the form in order to be treated?
	Yes      No
Is the signed form maintained in the patient’s record?
	Yes      No
Have you received training on arbitration?
	Yes      No
When was the last training that you received by our risk manager either by phone or in person?
	Date:     Risk Manager Name:
Contact Info (if we have questions about your order):
E-mail:
Daytime Telephone:

In addition to ordering online, you can also fax this completed form to (707) 226-0162 or mail it to:

The Doctors Company Arbitration Program 185 Greenwood Road Napa, CA 94558