Wisconsin Request for Mediation (Mediation Panel Filing) — Wis. Stat. ch. 655

REQUEST FOR MEDIATION — WISCONSIN MEDICAL MEDIATION PANEL (Wis. Stat. ch. 655)

TABLE OF CONTENTS

1. Statutory Framework Overview
2. Caption and Filing Information
3. Identification of Claimant(s)
4. Identification of Respondent(s) (Health Care Providers)
5. Statement of Claim and Factual Basis
6. Specification of Injuries and Damages
7. Statement of Mediation Period and Tolling Effect
8. Counsel for Claimant
9. Filing Fee and Service Information
10. Verification
11. Certificate of Service
12. Practice Notes and Coordination with Civil Action
13. Sources and References

1. STATUTORY FRAMEWORK OVERVIEW

Pursuant to Wis. Stat. § 655.42, the Wisconsin Legislature has established a system of medical mediation that provides "an informal, inexpensive and expedient means for resolving disputes" relating to medical malpractice claims, administered by the Director of State Courts under § 655.43.

Two filing pathways:

1. Pre-Suit Mediation Request — § 655.44. A claimant may file a Request for Mediation with the Director of State Courts before commencing a civil action. Under § 655.44(1), "no court action may be commenced unless a request for mediation has been filed under this section and until the expiration of the mediation period under s. 655.465(7)."

2. Contemporaneous Mediation Request — § 655.445. When a civil action is filed first, the claimant must file a Request for Mediation within fifteen (15) days of filing the action. Under § 655.445(2), no discovery, trial, pretrial conference, or scheduling conference may occur until the mediation period expires.

Tolling. Under Wis. Stat. § 655.44(4), the period of limitations applicable to the underlying medical malpractice action is tolled during the pendency of the mediation period.

Advisory Result. Under Wis. Stat. § 655.61, the result of mediation panel proceedings is advisory and does not preclude a subsequent civil action; however, participation is mandatory and the panel's analysis is confidential and inadmissible under § 655.58.

2. CAPTION AND FILING INFORMATION

STATE OF WISCONSIN — DIRECTOR OF STATE COURTS
MEDICAL MEDIATION PANELS
P.O. Box 1688, Madison, WI 53701-1688
(verify current address and form at www.wicourts.gov/courts/offices/mmp.htm)

Mediation File No.: [_______________] (assigned by Director of State Courts)
Date of Filing: [__/__/____]
Filing Pathway: ☐ Pre-suit (§ 655.44) ☐ Contemporaneous with civil action (§ 655.445)
Companion Civil Action (if any): [______] County Circuit Court Case No. [______]

3. IDENTIFICATION OF CLAIMANT(S)

Pursuant to Wis. Stat. § 655.44(2), Claimant identifies the following:

3.1 Patient (Injured Party).

• Name: [_______________]
• Date of birth: [__/__/____]
• Address: [_______________]
• Capacity: ☐ Living adult patient ☐ Minor (parent/guardian as next friend) ☐ Decedent (action by personal representative) ☐ Person under legal disability

3.2 Claimant(s) Filing This Request.

• Name: [_______________]
• Relationship to patient: ☐ Self ☐ Spouse ☐ Parent ☐ Minor child ☐ Sibling ☐ Personal Representative
• Address: [_______________]
• Telephone: [_______________]
• Capacity to sue confirmed under Wis. Stat. § 655.007

3.3 Letters of Authority / Probate Information (if applicable).

• Estate File No.: [______]
• Court of appointment: [______]
• Date of appointment: [__/__/____]

4. IDENTIFICATION OF RESPONDENT(S) (HEALTH CARE PROVIDERS)

Pursuant to Wis. Stat. § 655.44(2)(b), Claimant identifies each Respondent and confirms each is a "health care provider" within the meaning of Wis. Stat. § 655.001(8):

Respondent 1

• Name: [_______________], M.D./D.O./D.D.S./N.P./P.A.
• Specialty: [_______________]
• License No. (if known): [______]
• Practice address: [_______________]
• Service address (if different): [_______________]
• Primary insurer (if known): [_______________]
• Participating in IPFCF: ☐ Yes ☐ No ☐ Unknown

Respondent 2

• Name: [_______________]
• Type of entity: ☐ Hospital ☐ Clinic ☐ Surgery center ☐ Nursing home ☐ Other: [______]
• Address: [_______________]
• Registered agent for service: [_______________]
• Primary insurer (if known): [_______________]

Respondent 3 (add as necessary)

• [_______________]

5. STATEMENT OF CLAIM AND FACTUAL BASIS

Pursuant to Wis. Stat. § 655.44(2)(c), the Claimant provides the following concise statement of the basis for the claim:

5.1 Date(s) of Treatment Giving Rise to Claim: [__/__/____] through [__/__/____].

5.2 Facility Where Treatment Occurred: [_______________].

5.3 Treatment / Procedure / Encounter: [Describe the procedure, encounter, hospitalization, or course of care: e.g., elective laparoscopic cholecystectomy on [DATE]; emergency department evaluation for [SYMPTOMS]; obstetrical care from [DATE] through delivery on [DATE]; oncology follow-up between [DATES]].

5.4 Acts or Omissions Alleged. Claimant alleges that one or more Respondents departed from the applicable standard of care, including:

• ☐ Failure to timely or correctly diagnose [______]
• ☐ Failure to order appropriate diagnostic studies [______]
• ☐ Misinterpretation of diagnostic studies [______]
• ☐ Negligent surgical or procedural performance [______]
• ☐ Medication error (prescription, dispensing, administration, or monitoring) [______]
• ☐ Failure to obtain informed consent under Wis. Stat. § 448.30
• ☐ Failure to monitor or recognize deterioration [______]
• ☐ Failure to refer or consult [______]
• ☐ Negligent credentialing, supervision, or staffing [______]
• ☐ Failure to communicate critical findings [______]
• ☐ Other: [______]

5.5 Causal Connection. Claimant alleges that the foregoing departures from the standard of care were a substantial factor in causing injury to the patient.

6. SPECIFICATION OF INJURIES AND DAMAGES

6.1 Nature of Injury Sustained.

• ☐ Death of patient on [__/__/____]
• ☐ Permanent physical injury / disability: [______]
• ☐ Surgical injury or complication: [______]
• ☐ Brain injury / neurological injury
• ☐ Birth injury / fetal injury
• ☐ Cancer diagnosis delayed: [type/stage at diagnosis] [______]
• ☐ Loss of organ or limb: [______]
• ☐ Sensory loss (vision/hearing): [______]
• ☐ Psychological injury: [______]
• ☐ Other: [______]

6.2 Categories of Damages Sought.

• ☐ Past medical, hospital, rehabilitative, attendant care, and prescription expenses
• ☐ Future medical and life-care expenses
• ☐ Past lost earnings
• ☐ Future lost earnings and lost earning capacity
• ☐ Past and future pain, suffering, disability, disfigurement, and emotional distress (subject to § 893.55(4)(d) cap)
• ☐ Loss of society, companionship, services, and consortium (derivative claims)
• ☐ Wrongful death pecuniary loss and § 895.04(4) damages (if applicable)
• ☐ Funeral and burial expenses

6.3 Acknowledgment of Statutory Caps.

• Noneconomic damages cap of $750,000 per occurrence under Wis. Stat. § 893.55(4)(d), upheld in Mayo v. Wis. Injured Patients & Families Comp. Fund, 2018 WI 78.
• Wrongful death cap (if applicable): $350,000 (adult) / $500,000 (minor) under § 895.04(4).
• No cap on economic damages.
• Punitive damages governed by § 895.043 (cap of $200,000 or twice compensatory, whichever is greater).

6.4 Approximate Amount in Controversy (optional but customary). $[_______________].

7. STATEMENT OF MEDIATION PERIOD AND TOLLING EFFECT

7.1 Tolling. Pursuant to Wis. Stat. § 655.44(4), the period of limitations under Wis. Stat. § 893.55(1m) is tolled from the date this Request for Mediation is filed and remains tolled through the expiration of the mediation period prescribed by § 655.465(7).

7.2 Mediation Period — § 655.465(7). The mediation period generally extends ninety (90) days from the date the Request for Mediation is filed (or, where extended by stipulation under § 655.465(7), up to a further period as agreed). No civil action may be commenced before expiration of the mediation period under the pre-suit pathway (§ 655.44(1)); under the contemporaneous-filing pathway, no discovery, trial, pretrial conference, or scheduling conference may occur prior to expiration (§ 655.445(2)).

7.3 Confidentiality. All statements, communications, and documents prepared exclusively for the mediation are confidential under Wis. Stat. § 655.58 and are not admissible in any subsequent civil proceeding except as the statute permits.

7.4 Advisory Nature. The mediation panel's findings and recommendations are advisory under Wis. Stat. § 655.61 and do not preclude a subsequent civil action under Wis. Stat. ch. 655.

8. COUNSEL FOR CLAIMANT

9. FILING FEE AND SERVICE INFORMATION

9.1 Filing Fee. Pursuant to Wis. Stat. § 655.54 and the Director of State Courts' fee schedule, Claimant transmits a filing fee of $[______] (verify current amount).

9.2 Method of Service. Pursuant to Wis. Stat. § 655.45, the Director of State Courts shall serve a copy of this Request for Mediation on each Respondent. Claimant has provided the addresses for service in Section 4 above.

9.3 Time for Answer. Each Respondent is required, pursuant to Wis. Stat. § 655.455, to file an Answer within twenty (20) days of service.

9.4 Notice to IPFCF. A copy of this Request is being concurrently provided to the Wisconsin Injured Patients and Families Compensation Fund, c/o Office of the Commissioner of Insurance, 125 South Webster Street, Madison, WI 53703, where any Respondent is a participating provider whose claim may exceed primary policy limits.

10. VERIFICATION

STATE OF WISCONSIN )
) ss.
COUNTY OF [______] )

I, [CLAIMANT NAME], being first duly sworn on oath, depose and state:

1. I am the Claimant (or duly authorized representative of the Claimant) named in the foregoing Request for Mediation;

2. I have read the Request for Mediation, and the factual matters set forth therein are true to the best of my knowledge, information, and belief;

3. This Request is made in good faith and is not interposed for any improper purpose; and

4. The undersigned has been advised of the confidentiality, advisory nature, and tolling effect of the mediation proceedings under Wis. Stat. ch. 655.

______________________________
[CLAIMANT NAME]

Subscribed and sworn to before me this ______ day of ______________, 20____.

______________________________
Notary Public, State of Wisconsin
My Commission Expires: ______________

11. CERTIFICATE OF SERVICE

I hereby certify that on this ______ day of ______________, 20____, I caused a true and correct copy of the foregoing Request for Mediation to be served upon the following by [☐ U.S. Mail, postage prepaid ☐ Personal Service ☐ Email by stipulation]:

• Director of State Courts, Medical Mediation Panels, P.O. Box 1688, Madison, WI 53701-1688 (via official filing)
• [Each Respondent and counsel of record, if known]
• Wisconsin Injured Patients and Families Compensation Fund, c/o Office of the Commissioner of Insurance, 125 South Webster Street, Madison, WI 53703
• [Primary insurer(s) of Respondent(s), if known]

______________________________
[ATTORNEY NAME]

12. PRACTICE NOTES AND COORDINATION WITH CIVIL ACTION

12.1 Strategic Sequencing.

• Pre-Suit Pathway (§ 655.44): Useful when SOL allows time and counsel desires to test claim value, force early disclosure, or obtain panel reaction before incurring filing fees and litigation costs.
• Contemporaneous Pathway (§ 655.445): Necessary when SOL is imminent and a civil action must be filed to preserve the claim. Mediation request must be filed within 15 days of the civil action.

12.2 IPFCF Coordination. Where damages are likely to exceed the $1M primary limit (or $3M aggregate), the IPFCF must be joined in the eventual civil action under § 655.27(5). The Fund typically receives notice of the mediation request and may participate.

12.3 Expert Disclosures. Although not required at the mediation panel stage, retain a qualified expert under § 907.02 prior to filing both because (a) most counsel use the panel as a settlement vehicle that benefits from credible expert input; and (b) the eventual civil action will require expert testimony to survive summary judgment under Carney-Hayes v. Nw. Wis. Home Care, 2005 WI 118.

12.4 Apology Statute. Counsel should remember that under Wis. Stat. § 904.14, statements of apology, sympathy, or remorse made before commencement of a civil action are inadmissible — including in the mediation panel proceeding.

12.5 County-Level Coordination.

• Milwaukee County: Companion civil filings tracked in Civil Division; check local rules for stays pending mediation.
• Dane County: Some judges issue stays sua sponte once Mediation Panel is filed.
• Waukesha County: Verify local case-management orders.
• Brown County: Coordinate with court's scheduling clerk regarding § 655.445(2) discovery stay.

12.6 Mediation Panel Composition (§ 655.465). The panel is comprised of:

• One attorney licensed in Wisconsin;
• One health care provider licensed in Wisconsin (matched to respondent's specialty under § 655.465(2));
• One public/lay member who is neither an attorney nor a health care provider.

12.7 Failure to Participate. A claimant who fails to participate in good faith in the mediation panel proceedings risks dismissal of the underlying action under § 655.44(1) and applicable case law.

13. SOURCES AND REFERENCES

Primary Authority — Wisconsin Statutes (verify at docs.legis.wisconsin.gov)

• Wis. Stat. § 655.001 — Definitions
• Wis. Stat. § 655.007 — Patients' claims (who may bring claim)
• Wis. Stat. § 655.013 — Contingency fee limits
• Wis. Stat. § 655.27 — Injured Patients and Families Compensation Fund
• Wis. Stat. § 655.42 — Legislative intent (mediation system)
• Wis. Stat. § 655.43 — Director of State Courts administration
• Wis. Stat. § 655.44 — Pre-suit Request for Mediation (mandatory before action)
• Wis. Stat. § 655.445 — Contemporaneous Request for Mediation (within 15 days of filing)
• Wis. Stat. § 655.45 — Filing fee and service by Director
• Wis. Stat. § 655.455 — Answer (20 days)
• Wis. Stat. § 655.46 — Mediation panel
• Wis. Stat. § 655.465 — Mediation panels; mediation period (90 days); panel composition
• Wis. Stat. § 655.54 — Fee schedule
• Wis. Stat. § 655.58 — Confidentiality
• Wis. Stat. § 655.61 — Advisory nature of mediation
• Wis. Stat. § 893.55 — Medical malpractice statute of limitations and damages cap
• Wis. Stat. § 893.56 — Medical malpractice involving minors
• Wis. Stat. § 904.14 — Apology statute
• Wis. Stat. § 907.02 — Expert testimony standard

Key Case Law

• Mayo v. Wis. Injured Patients & Families Comp. Fund, 2018 WI 78 (cap upheld)
• Bartholomew v. Wis. Patients Comp. Fund, 2006 WI 91 (caps in death cases)
• Phelps v. Physicians Ins. Co., 2009 WI 74 (causation; loss of chance)
• Seifert v. Balink, 2017 WI 2 (expert testimony / Daubert)
• Carney-Hayes v. Nw. Wis. Home Care, 2005 WI 118 (expert testimony required)

Official Resources (Verify Before Filing)

• Wisconsin Court System — Medical Mediation Panels: https://www.wicourts.gov/courts/offices/mmp.htm (official forms, fee schedule, contact information)
• Director of State Courts: Office address and current filing procedures
• Office of the Commissioner of Insurance — IPFCF: https://oci.wi.gov/Pages/Funds/IPFCFOverview.aspx
• Wisconsin State Law Library — Medical Mediation: https://wilawlibrary.gov/topics/medlaw/mediation.php
• Wisconsin State Law Library — Medical Malpractice: https://wilawlibrary.gov/topics/medlaw/malpractice.php

Verification Checklist

☐ Confirmed current official Request for Mediation form (CV-440 series) at wicourts.gov
☐ Confirmed current filing fee under § 655.54
☐ Confirmed all Respondents are "health care providers" under § 655.001(8)
☐ Confirmed claim is within § 893.55(1m) limitations period
☐ Confirmed proper service addresses for each Respondent
☐ Confirmed IPFCF notice provided
☐ Confirmed contingency fee agreement complies with § 655.013
☐ Confirmed companion civil action (if any) coordinated with mediation
☐ Confirmed expert review obtained (best practice, not statutorily required)
☐ Confirmed compliance with § 904.14 (apology statements treated as inadmissible)

This template does not constitute legal advice. Wisconsin's Mediation Panel filing is a unique procedural prerequisite to a medical malpractice civil action. Counsel must verify all citations, fee amounts, and current official forms with the Wisconsin Director of State Courts before filing.