HEALTHCARE SUBMISSION TO DISPUTE RESOLUTION The named parties hereby submit the following dispute for resolution, under the rules of the American Arbitration Association. To be completed and signed by all parties (attach additional sheets if necessary). Rules Selected Commercial Healthcare Payor Provider Employment or Other (please specify)________________________________ Procedure Selected Binding Arbitration Mediation Other (please specify) ____________________________________________________ NATURE OF DISPUTE: Healthcare Corporate Transactions & Contracting Issues Payor Provider Reimbursement Credentialing / Peer Review & Hospital Governing Board Authority Healthcare Provider Contract Issues Medical Malpractice Other ____________________________________________ Other Relief Sought: Attorneys Fees Interest Arbitration Cost Punitive / Exemplary Other ____________________________________________ PLEASE DESCRIBE APPROPRIATE QUALIFICATIONS FOR NEUTRAL(S) TO BE APPOINTED TO HEAR THIS DISPUTE: Dollar Amount of Claim $ PLEASE FILE A COPY ALONG WITH THE FILING FEE AS PROVIDED FOR IN THE RULES, TO THE AAA Case Filing Services, 1101 Laurel Oak Road, Suite 100, Voorhees, NJ 08043 Fax: 877- 304-8457 CaseFiling@adr.org AND COPY THE RESPONDENT. Amount Enclosed (if filing for arbitration.) $ _________________________ In accordance with Fee Schedule: Flexible Fee Schedule Standard Fee Schedule Estimated time needed for hearings overall: Hearing Locale Requested ___________________ _________ hours or _______ days We agree that, if Arbitration is selected, we will abide by and perform any award rendered hereunder and that a judgment may be entered on the award. Name of Party Name of Party Address: Address: Address: Address: City: Phone # E-mail Address: Signature (required) State Fax # Zip City: Phone # E-mail Address: Signature (required) State Fax # Zip Name of Representative Name of Representative Name of Firm Address (to be used in connection with this case) Name of Firm Address (to be used in connection with this case) City Phone # E-mail Address State Zip Fax # City Phone # E-mail Address State Zip Fax # 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