Superior Court of the District of Columbia MULTI-DOOR MEDICAL MALPRACTICE EARLY MEDIATION FORM To be used in selecting a mediator from the Multi-Door Medical Malpractice Mediator Roster and scheduling a mediation date through the Multi-Door Dispute Resolution Division. Case Number Case Caption Undersigned counsel, as well as individual parties, representatives of non-individual parties with settlement authority, and involved insurance companies with the required settlement authority, have agreed to be available for mediation on the three dates listed below, from 1:00 pm to 5:00 pm. All listed dates occur after the Initial Scheduling and Settlement Conference and within 30 days of that date, as required under D.C. Code 24716-2821. Date Date Date Parties have reviewed the Multi-Door Medical Malpractice Mediation Roster and have agreed on the following mediators, listed below in order of preference: First Mediator Second Mediator Third Mediator Submitted by: Signature Date Atty. for: E-mail address: (or telephone number, if no e-mail address) Signature Date Atty. for: E-mail address: (or telephone number, if no e-mail address) Signature Date Atty. for: E-mail address: (or telephone number, if no e-mail address) The completed form must be filed with the court and e-mailed to: earlymedmal@dcsc.gov. Those unable to eFile may -Door Dispute Resolution Division, 410 E St. NW, Suite 2900, Washington, DC 20001. Multi-Door will notify counsel or pro se parties promptly, by e-mail, when the mediation date has been set. American LegalNet, Inc. www.FormsWorkFlow.com