Medical Malpractice Settlement

ARIZONA MEDICAL MALPRACTICE SETTLEMENT AGREEMENT AND RELEASE

Use gate: This form is designed for a living, competent adult settling that adult's own claim arising from identified Arizona health care. A.R.S. § 12-561 defines a medical malpractice action by reference to a claim against a licensed health care provider arising from alleged negligence, misconduct, error, omission, breach of contract, or lack of consent in rendering covered services. Do not use an ordinary adult signature block for a minor or adult in need of protection; Arizona Rule of Probate Procedure 53 governs those settlements. Use a claim-specific agreement for death, estate, survival, bankruptcy-estate, or other representative claims.

1. SETTLEMENT PROFILE

This Agreement is made as of [__/__/____] by the following persons and entities:

Only the persons and entities individually named in Exhibit A receive a release. A parent, affiliate, employee, contractor, insurer, or other person is not released merely because a category appears in boilerplate.

1.1 Claim and proceeding

The parties dispute liability, causation, damages, defenses, and all matters not expressly admitted in this Agreement. This settlement is a compromise and not an admission of malpractice, fault, damages, or professional discipline.

2. AUTHORITY AND APPROVAL GATES

Complete every applicable item before funding:

• ☐ Claimant is an adult with capacity and owns the claims being settled.
• ☐ Every loss-of-consortium or other derivative claimant is identified and either signs or is expressly excluded.
• ☐ No patient death, estate, survival, or wrongful-death claim is involved.
• ☐ No claimant is a minor or adult in need of protection.
• ☐ If a minor or adult in need of protection is involved, counsel has used Arizona Rule of Probate Procedure 53 and obtained every required representative appointment, petition, notice, hearing, finding, order, restricted account, conservatorship, trust, annuity, or other protection.
• ☐ Any personal representative, guardian, conservator, bankruptcy trustee, assignee, benefit plan, insurer, or other person with ownership or control of a claim is identified.
• ☐ Every required corporate, insurer, governmental, and court approval is attached in Exhibit B.
• ☐ Each person signing for an entity or another person has written authority.

Unresolved authority or approval issue: [NONE / DESCRIBE]

No release becomes effective for a claim that the signer does not own or have authority to settle.

3. SETTLEMENT CONSIDERATION

3.1 Gross amount and administration

Subject to the conditions in this Agreement, [PAYOR] shall fund a gross settlement amount of $[________].

Payment method: ☐ wire transfer ☐ trust check ☐ cashier's check ☐ other: [________________________________].

Receiving trust account or escrow: [________________________________]

Funding deadline: [__/__/____], subject only to: [________________________________].

The allocation is for settlement administration and does not bind a tax authority, benefit program, recovery claimant, or other nonparty.

3.2 Structured settlement

☐ No structured settlement is used.

☐ A structured settlement is stated in Exhibit C. The exhibit identifies the assignment, assignee, annuity issuer, exact payment schedule, rated-age assumptions, death-benefit terms, beneficiary designation, fees, ownership, anti-assignment terms, and insolvency risk. No party promises tax treatment, present value, rating, acceleration, commutation, or joint liability unless Exhibit C accurately states that term after tax, benefits, and structured-settlement review.

3.3 Nonmonetary consideration

• ☐ None.
• ☐ Medical-record correction or addendum process: [________________________________].
• ☐ Return of property or records: [________________________________].
• ☐ Written communication: [________________________________].
• ☐ Other lawful term: [________________________________].

No term requires a false record or report, interference with a regulator, or waiver of a duty that cannot be waived.

4. MEDICARE, AHCCCS, AND OTHER RECOVERY CLAIMS

4.1 Recovery inventory

4.2 Medicare conditional-payment process

If Medicare made a conditional payment, 42 C.F.R. § 411.24 gives CMS recovery rights against primary payers and entities receiving a primary payment. A beneficiary or other party receiving a primary payment must reimburse Medicare within 60 days. For a liability settlement, a primary payer may remain responsible if Medicare is not reimbursed even after the payer paid another party and knew or should have known of Medicare's conditional payment.

Before unrestricted distribution, the responsible parties shall:

1. confirm Medicare status and case identifiers;
2. report the claim and settlement through the applicable CMS process;
3. obtain and review conditional-payment information;
4. request the final demand or other required final amount;
5. preserve the agreed holdback until resolution; and
6. retain proof of payment, waiver, compromise, appeal, or other closure.

Medicare holdback release instruction: [________________________________]

4.3 Other recovery claims

Claimant does not warrant that every governmental or private recovery claim is already known or finally calculated. The parties instead adopt the inventory, notice, escrow, cooperation, dispute, and payment process stated here.

Responsibility for an omitted or later-adjusted interest, subject to nonwaivable law: [________________________________]

No party may impair a nonparty's rights by an allocation, release, or characterization inconsistent with the facts.

5. RELEASE

5.1 Released Occurrence

“Released Occurrence” means only the care, acts, omissions, events, injuries, and damages identified in Section 1.1 and Exhibit D, during [DATE] through [DATE].

5.2 Claimant's release

When the conditions in Section 5.5 are satisfied, Claimant releases each person specifically named in Exhibit A from claims that Claimant owns as of the Effective Date, whether presently known or unknown, arising from the Released Occurrence.

5.3 Claims not released

The release does not include:

• duties created by this Agreement or an approved structured-settlement exhibit;
• care, conduct, or injuries outside the Released Occurrence;
• later independent malpractice or other future conduct;
• a claim owned by a nonsigning spouse, child, estate, bankruptcy estate, government, benefit plan, insurer, or other person;
• Medicare, Medicaid, tax, child-support, reimbursement, reporting, licensing, disciplinary, or regulatory rights of a nonparty;
• a workers' compensation or employment claim unless expressly identified and lawfully released in Exhibit D; or
• a right that applicable law does not permit Claimant to waive.

5.4 Derivative claimant release

Each listed derivative claimant releases only that claimant's own claims arising from the Released Occurrence, subject to Section 5.3.

5.5 Release effective conditions

The release becomes effective only when:

1. all required parties have signed;
2. all required court and representative approvals are entered and final;
3. cleared funds and any structured-settlement funding are delivered;
4. all required holdbacks are funded; and
5. Claimant receives a completed copy of this Agreement and its exhibits.

If those conditions are not satisfied by [__/__/____], the consequence is: [TERMINATION / EXTENSION / OTHER]. Any claim-preservation plan pending funding is: [________________________________].

5.6 Provider release — select one

☐ Provider gives no affirmative release beyond accepting Claimant's performance and the agreed dismissal.

☐ Provider releases Claimant from the following specifically identified claims: [________________________________].

6. DISMISSAL, DEFAULT, AND ENFORCEMENT

6.1 Dismissal sequence

If an action is pending, Claimant's counsel shall hold signed dismissal papers in trust and file them only after:

1. cleared funding and required holdbacks;
2. entry of every required minor, protected-person, probate, bankruptcy, or other approval order;
3. confirmation of the parties and claims being dismissed; and
4. satisfaction of every action-specific filing condition.

The dismissal shall be ☐ with prejudice as to released parties and claims ☐ other: [________________________________].

Costs are allocated as follows: [________________________________].

If the parties want the pending court to retain settlement-enforcement authority after dismissal, counsel shall obtain any required order before closing the case.

6.2 Payment default

If required funding is not delivered when due, Claimant shall give detailed written notice and [____] business days to cure unless a nonwaivable deadline or court order requires earlier action. After an uncured default, Claimant may seek the unpaid amount and other relief permitted by this Agreement and applicable law.

Optional agreed interest on an uncured amount: [____]% per year, not exceeding the lawful rate. ☐ No default interest selected.

6.3 Other breach

A curable nonpayment breach has a cure period of [____] business days after detailed written notice. No cure period applies when a court order or nonwaivable law requires immediate action.

6.4 Attorneys' fees — select one

☐ Each party bears its own enforcement fees and costs except where law provides otherwise.

☐ The substantially prevailing party may recover reasonable enforcement fees and costs, subject to judicial review.

☐ Other: [________________________________].

6.5 No automatic stipulated judgment

No consent or stipulated judgment may be entered unless its amount, credits, notice, cure, filing conditions, and scope are stated in a separately signed exhibit and any required court approval is obtained.

7. REPORTING, CONFIDENTIALITY, AND STATEMENTS

7.1 NPDB and licensing-board reporting

Under 45 C.F.R. §§ 60.5 and 60.7, each entity that makes a payment for the benefit of a health care practitioner in settlement or partial settlement of a medical malpractice claim must report the payment to the National Practitioner Data Bank and the appropriate state licensing board within 30 days. The reporting entity is the entity making the payment, not automatically the Provider.

The parties shall provide accurate information reasonably required for a lawful report. Under 45 C.F.R. § 60.7(d), a settlement payment does not create a presumption that medical malpractice occurred. Nothing in this Agreement changes reportability, directs a false characterization, or structures payment to evade reporting.

7.2 Confidentiality election

☐ No contractual confidentiality obligation.

☐ The parties will not voluntarily disclose the settlement amount or nonpublic terms except as this section permits.

Any confidentiality obligation permits disclosure to courts, regulators, licensing boards, the NPDB, CMS, AHCCCS or another Medicaid agency, tax authorities, benefit programs, recovery claimants, insurers, reinsurers, auditors, attorneys, tax and financial advisors, immediate family or caregivers who agree to confidentiality, and as otherwise required to perform or enforce the settlement. It does not restrict truthful testimony, protected reporting, cooperation with government, or information already lawfully public.

Before filing this Agreement, counsel shall decide whether to seek a redacted filing, separate approval record, sealing order, or other lawful protection. No party promises that a court will seal a record.

7.3 Statements about the dispute

☐ No non-disparagement term.

☐ The parties shall not knowingly publish a false statement of fact about the Released Occurrence or settlement. This term does not prohibit opinions, truthful statements, privileged communications, required reports, testimony, or protected government communications.

8. TAX, BENEFITS, AND DISPUTE PROCESS

8.1 Tax and benefits

Each recipient shall obtain independent tax advice. No party guarantees exclusion from income, allocation, deductibility, reporting form, or treatment of attorney fees, interest, structured payments, confidentiality consideration, or another component.

Before funding, Claimant shall obtain advice concerning Medicare, AHCCCS, SSI, disability, means-tested benefits, special-needs planning, and any other affected benefit. Any trust or planning vehicle must be separately established and approved before transfer.

This Agreement does not promise CMS approval of a future-medical allocation or shift responsibility for future care contrary to law. The parties' factual statement concerning future care is: [________________________________].

8.2 Governing law and forum

Arizona law governs this Agreement, except that controlling federal law governs federal reporting, Medicare, tax, and benefit issues.

An enforcement action may be brought only in a court with subject-matter jurisdiction and lawful venue. Agreed Arizona forum, if enforceable: [________________________________].

8.3 Arbitration — select at signing

☐ No arbitration provision is selected.

☐ The parties agree now—not by a later unilateral election—to submit the following settlement-enforcement disputes to binding arbitration: [SCOPE]. The selected administrator and rules are [________________________________]; seat is [________________________________]; arbitrator count is [____]; fees are allocated [________________________________]; provisional-relief terms are [________________________________]; and judgment on an award may be sought in a court with jurisdiction.

Claimant initials: ________ Provider initials: ________ Payor initials: ________

8.4 Jury trial

No jury-trial waiver is included. Any proposed waiver must be separately drafted and reviewed under current law for the parties, agreement, and dispute involved.

9. GENERAL PROVISIONS

9.1 Claimant representations

After reasonable inquiry, Claimant represents that:

• known assignments, bankruptcy interests, derivative claims, recovery claims, and benefit interests are disclosed in Exhibit E;
• Claimant has not sold or released the claims except as disclosed;
• Claimant reviewed the Agreement and had an opportunity to consult counsel; and
• Claimant is not relying on an unwritten tax, benefits, reporting, licensing, or future-care promise.

9.2 Provider and payor representations

Provider and Payor represent that their signers have authority, funding instructions accurately state the agreed consideration, and each required reporting or payment-administration process has an identified owner.

9.3 Notices

Contract notices shall be delivered to the party and counsel contacts in Section 1 by [PERSONAL_DELIVERY / OVERNIGHT_SERVICE / CERTIFIED_MAIL / AGREED_EMAIL]. Notice is effective: [________________________________]. Court, government, insurer, NPDB, and recovery notices must follow the rules governing them.

9.4 Entire agreement; amendments

This Agreement and signed Exhibits A through [____] are the entire settlement. An amendment or waiver must be in a writing signed by the affected parties and approved by a court or representative when the original agreement required that approval.

9.5 Severability

An unenforceable provision shall be severed or enforced only to the lawful extent. No court may broaden the Released Occurrence, released parties, or released claims beyond the signed description.

9.6 Counterparts and electronic signatures

The parties may sign counterparts and exchange signature copies electronically, subject to any court, probate, conservatorship, insurer, notarization, identity, or record requirement identified by counsel.

9.7 Assignment

No party may assign this Agreement except as expressly permitted in an approved structured-settlement, insurer-payment, trust, estate, or court document. An assignment does not eliminate the assignor's duties unless the affected party expressly agrees.

10. EXECUTION BLOCK

CLAIMANT

DERIVATIVE CLAIMANT, IF ANY

PROVIDER / SETTLING DEFENDANT

ADDITIONAL SETTLING DEFENDANT

INSURER OR OTHER PAYOR — FUNDING AND REPORTING ACKNOWLEDGMENT

COUNSEL APPROVAL

EXHIBITS

• Exhibit A: Individually named released parties.
• Exhibit B: Authority, representative, insurer, and court approvals.
• Exhibit C: Structured-settlement terms, if any.
• Exhibit D: Released Occurrence and released-claim schedule.
• Exhibit E: Medicare, AHCCCS, recovery, assignment, bankruptcy, benefits, and derivative-claim disclosures.
• Exhibit F: Funding, escrow, and holdback instructions.
• Exhibit G: Dismissal papers and approval orders.
• Exhibit H: Other: [________________________________].

OFFICIAL SOURCES AND VERIFICATION NOTES

• Arizona Legislature, A.R.S. § 12-561 — Definitions
• Arizona Supreme Court Order R-18-0044 adopting the Arizona Rules of Probate Procedure, including Rule 53
• eCFR, 42 C.F.R. § 411.24 — Recovery of conditional payments
• eCFR, 45 C.F.R. Part 60 — National Practitioner Data Bank, including §§ 60.5 and 60.7

Currency note: The official consolidated A.R.S. § 12-561 page was checked through the verification date. The 2025-2026 Arizona bill-text screen found no enacted amendment changing the definition used here. Federal regulation currency checks found no 2025-2026 change to 45 C.F.R. Part 60 affecting the reporting terms used here; current § 411.24 text was separately retrieved after the broader Part 411 change screen.

END OF DOCUMENT