Ohio Revised Code Title XXVII. Courts Revised Code General Provisions Special Remedies § 2711.24

(1) Care, diagnosis, or treatment will be provided whether or not the patient signs the agreement to arbitrate;

(2) The agreement may not even be submitted to a patient for approval when the patient's condition prevents the patient from making a rational decision whether or not to agree;

(3) The decision whether or not to sign the agreement is solely a matter for the patient's determination without any influence;

(4) The agreement waives the patient's right to a trial in court for any future malpractice claim the patient may have against the healthcare provider;

(5) The patient must be furnished with two copies of this agreement.

The patient, or the patient's spouse or the personal representative of the patient's estate in the event of the patient's death or incapacity, has the right to cancel this agreement to arbitrate by notifying the healthcare provider in writing within thirty days after the patient's signing of the agreement. The patient, or the patient's spouse or representative, as appropriate, may cancel this agreement by merely writing “cancelled” on the face of one of the patient's copies of the agreement, signing the patient's name under such word, and mailing, by certified mail, return receipt requested, the copy to the healthcare provider within the thirty-day period.

Filing of a medical claim in a court within the thirty days provided for cancellation of the arbitration agreement by the patient will cancel the agreement without any further action by the patient.

Date:

Signature of Provider of Medical Services

Signature of Patient”