37 Pa. Code § 171.152
The following is the form for notice complaint
COMMONWEALTH OF
PENNSYLVANIA
ARBITRATION PANELS FOR
HEALTH CARE
vs. | : | No. |
County: |
NOTICE COMPLAINT
TO:___________________
Name of Defendant(s)
You are hereby notified that the Plaintiff(s)___________ allege(s) that the Defendant(s)___________ (has)(have) committed a tort or breach of contract causing injury or death to__________ resulting from the furnishing of medical services which were or which should have been provided.
Wherefore, plaintiff(s) request(s) arbitration of this claim under the Health Care Services Malpractice Act, 40 P. S. § 1301.101 et seq., and judgment in (his)(her) (their) favor.
___________ | By: ___________ |
Date | Attorney for Plaintiffs |
37 Pa. Code § 171.152
This section cited in 37 Pa. Code § 171.23 (relating to commencement of proceedings).