MEDIATION: If you would like the AAA to contact the other parties and attempt to arrange mediation, please check this box. There is no additional fee for this service. Name of Respondent Name of Representative (if known) HEALTHCARE COMMERCIAL DEMAND FOR ARBITRATION Address Name of Firm (if applicable) Address City Phone # E-Mail Address State Zip Code Fax # Representative's Address City Phone # E-Mail Address State Zip Fax # The named claimant, a party to an arbitration agreement dated ________________________________, which provides for arbitration under the Rules of the American Arbitration Association, hereby demands arbitration. Please check the appropriate box(s) that best describes the area of your dispute: Healthcare Corporate Transactions & Contracting Issues Payor Provider Reimbursement Credentialing /Peer Review & Hospital Governing Board Authority Healthcare Provider Contract Issues Other:_________________________________ THE NATURE OF THE DISPUTE: (Please note this form is not to be used for consumer disputes) Dollar Amount of Claim $ Other Relief Sought: Attorney's Fees Interest Arbitration Cost Punitive / Exemplary Other: ___________________ In accordance with Fee Schedule: Flexible Fee Schedule Standard Fee Schedule Amount Enclosed $ ____________________ PLEASE DESCRIBE APPROPRIATE QUALIFICATIONS FOR ARBITRATOR(s) TO BE APPOINTED TO HEAR THIS DISPUTE: Hearing Locale ____________________________ (check one) Requested by Claimant Estimated time needed for hearing overall: Type of Business: Claimant:_______________________________________ ________ hours: or _______days Respondent:_____________________________________ You are hereby notified that copies of our arbitration agreement and this demand are being filed with the American Arbitration Association, Case Filing Services (Check one), Mail: 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043 Fax: 877- 304-8457 E-mail: CaseFiling@adr.org with a request that it commence administration of the arbitration. Under the rules, you may file an answering statement within fifteen days after notice from the AAA. Signature (may be signed by a representative) Date: Name of Representative Locale provision included in the contract Name of Claimant Name of Firm (if applicable) Address Representative's Address City Phone # E-Mail Address State Zip Fax # City Phone # E-Mail Address State Zip Fax # To begin proceedings, please send a copy of this Demand and a copy of the parties' agreement naming the American Arbitration Association along with the filing fee as provided for in the Rules, to the AAA. Send the original Demand to the Respondent. Please visit our website at www.adr.org if you would like to file this case online. AAA Case Filing Services can be reached at 877-495-4185. American LegalNet, Inc. www.FormsWorkFlow.com