Superior Court of the District of Columbia PRIVATE EARLY MEDIATION FORM for Medical Malpractice Mediation To be used to notify the court of the selection of a private mediator and a scheduled mediation date in a medical malpractice matter. Case Number Case Caption Undersigned counsel have hired a private mediator, , (name of mediator) medical de 24716-2821. Mediation of this matter is scheduled on at , (date) (time) which is no later than 30 days after the Initial Scheduling and Settlement Conference. The mediator will complete a mediation report (available at www.dccourts.gov/medmalmediation ) at the conclusion of the mediation, to be filed with the court by the plaintiff. Submitted by: Signature Date Atty. for: Signature Date Atty. for: The completed form must be filed with the court and e-mailed to: earlymedmal@dcsc.gov . Those unable to eFile may ti-Door Dispute Resolution Division, 410 E St. NW, Suite 2900, Washington, DC 20001. American LegalNet, Inc. www.FormsWorkFlow.com