Colorado Medical Malpractice Settlement Agreement and Release

COLORADO MEDICAL MALPRACTICE SETTLEMENT AGREEMENT AND GENERAL RELEASE

CAPTION (if filed in litigation)

District Court, [____] County, Colorado — Case No. [____]

PARTIES TO THIS AGREEMENT

This Settlement Agreement and General Release ("Agreement") is entered into on [__/__/____] (the "Effective Date").

RECITALS

A. Claimant alleges that on or about [__/__/____], Released Party provided medical care that resulted in alleged injury to [Claimant / Decedent / Minor], as more fully described in [the Complaint filed in the above-captioned action / Claimant's pre-suit notice dated [__]] (the "Claim").

B. Released Party denies any negligence, breach of standard of care, or liability whatsoever.

C. The Parties, without admission of liability and to avoid the expense, delay, and uncertainty of further litigation, desire to fully and finally compromise and settle all claims arising from the Claim.

D. The Parties acknowledge the limitations on damages set forth in C.R.S. § 13-64-302 and § 13-21-102.5 and that this settlement is informed by, but is not an admission of liability under, those statutes.

NOW, THEREFORE, in consideration of the mutual covenants below and other good and valuable consideration, the Parties agree as follows.

1. SETTLEMENT PAYMENT

1.1 Total Settlement Amount. In full and final settlement, Insurer/Released Party shall pay Claimant the total gross sum of $[__________] (the "Settlement Amount"), allocated as follows:

1.2 Form of Payment.

☐ Lump Sum. Payable by check or wire within [30] days of the later of: (a) execution of this Agreement; (b) court approval if required; (c) resolution of all liens; and (d) delivery of all required tax/identification forms.

☐ Structured Settlement / Periodic Payments. Pursuant to C.R.S. § 13-64-205 and 26 U.S.C. § 130, a portion of the Settlement Amount, specifically $[______], shall fund a qualified assignment to [ASSIGNEE/ANNUITY ISSUER] providing the following periodic payments to Claimant: [SCHEDULE OF PAYMENTS ATTACHED AS EXHIBIT A]. The structured component is not subject to acceleration, increase, decrease, anticipation, or encashment except as provided in the qualified assignment.

1.3 Court Approval. ☐ Required for minor/incompetent claimant; petition for approval to be filed in [____] County District Court / Probate Court. Payment contingent on court order approving the settlement and any conservatorship/trust arrangement.

1.4 Allocation for Tax Purposes. The Parties agree the Settlement Amount is paid on account of personal physical injury or physical sickness within the meaning of 26 U.S.C. § 104(a)(2) and is intended to be excludable from Claimant's gross income except for portions, if any, allocated to: (a) punitive damages; (b) interest; (c) lost wages independent of physical injury; or (d) emotional distress not attributable to physical injury. The Parties make no representations or warranties as to the ultimate tax treatment, and Claimant has been advised to consult an independent tax advisor.

2. LIEN RESOLUTION; MEDICARE / MEDICAID COMPLIANCE

2.1 Medicare Secondary Payer. Claimant represents whether Claimant: ☐ is currently a Medicare beneficiary; ☐ has a pending Medicare application; ☐ has a known expected Medicare enrollment date of [____]; ☐ none of the above; ☐ unknown pending verification. A fixed 30-month inquiry is not a general liability-settlement recovery or set-aside rule; it is one element of CMS's voluntary workers' compensation MSA review thresholds.

2.2 Reporting. Insurer/Released Party shall comply with Section 111 reporting requirements under 42 U.S.C. § 1395y(b)(8). Claimant shall cooperate by providing HICN/Medicare beneficiary number, SSN, and dates of injury and treatment.

2.3 Medicare Conditional Payments. Claimant is responsible for full satisfaction of any conditional payment obligation to CMS/BCRC and shall provide proof of resolution before disbursement of Net Settlement Proceeds. Claimant indemnifies and holds Released Party and Insurer harmless from any Medicare recovery claim.

2.4 Medicare Set-Aside. ☐ MSA not required (state basis); ☐ MSA in the amount of $[____] established and funded as set forth in Exhibit B.

2.5 Medicaid Recovery Claim. As an allocation of responsibility between the Parties, and subject to the federal third-party-liability requirements in 42 U.S.C. § 1396a(a)(25) and current Colorado HCPF recovery law, Claimant shall resolve any asserted Colorado Medicaid recovery claim from the Settlement Amount and indemnify Released Party.

2.6 Other Liens. Claimant shall satisfy any ERISA plan, private health insurer, hospital, workers' compensation, child-support, or attorney's lien, and shall provide written lien releases or letters of satisfaction prior to disbursement.

2.7 Indemnification. Claimant agrees to defend, indemnify, and hold harmless Released Party and Insurer from and against any claim, demand, lien, subrogation, or recovery asserted by any governmental or private payor arising out of payments made on Claimant's behalf for the Claim, including reasonable attorneys' fees.

3. RELEASE OF CLAIMS

3.1 General Release. Claimant, on behalf of Claimant and Claimant's heirs, executors, administrators, successors, and assigns, fully, finally, and forever RELEASES AND DISCHARGES [Released Parties], their employers, employees, partners, shareholders, officers, directors, agents, insurers, reinsurers, attorneys, predecessors, and successors (collectively the "Released Parties") from any and all claims, demands, actions, causes of action, damages, costs, attorney's fees, and liabilities of every kind and nature, known or unknown, suspected or unsuspected, arising out of or related to the Claim, including but not limited to claims for negligence, medical malpractice, lack of informed consent, vicarious liability, EMTALA, products liability, fraud, outrage, loss of consortium, wrongful death, and any derivative claim.

3.2 Scope. The release covers all claims existing on the Effective Date, whether or not Claimant now knows or suspects them, and Claimant expressly waives the protection of any statute or common-law rule that would limit the effect of a general release to claims known at signing.

3.3 Reservation. The release does NOT apply to: (a) enforcement of this Agreement; (b) ☐ [other identified reservations]; (c) the structured-settlement payment obligations described in Section 1.2.

3.4 No Admission. This Agreement is a compromise of disputed claims; nothing herein is or shall be construed as an admission of liability or fault by any Released Party.

4. CONFIDENTIALITY AND NON-DISPARAGEMENT (COLORADO POWR ACT COMPLIANT)

4.1 Confidentiality of Terms. The financial terms of this settlement (Settlement Amount, allocation, and payment schedule) shall remain confidential and shall not be disclosed by Claimant except to: (a) Claimant's spouse, immediate family, attorneys, accountants, and tax/financial advisors; (b) governmental authorities, including the IRS and CMS, as required by law; (c) lienholders for lien-resolution purposes; (d) in response to lawful subpoena or court order, with prompt notice to Released Party; (e) Claimant's mental-health or medical providers; or (f) as otherwise required by law.

4.2 Permitted Disclosures. Nothing in this Agreement prohibits Claimant from: (a) reporting potential violations of law to any federal, state, or local agency, including the Colorado Medical Board, DORA, OCR, OIG, CMS, EEOC, NLRB, or SEC; (b) participating in any government investigation; (c) discussing the underlying facts of the Claim with healthcare providers for purposes of medical care; (d) cooperating with NPDB reporting; or (e) exercising rights under 18 U.S.C. § 1833(b) (Defend Trade Secrets Act whistleblower immunity).

4.3 Non-Disparagement. ☐ Mutual non-disparagement, subject to all Permitted Disclosures in § 4.2. ☐ Not included.

4.4 Patient-Safety Reporting. Nothing herein restricts or is intended to restrict reporting of any patient-safety event to any regulatory body, accreditation organization, or NPDB.

5. NPDB AND REGULATORY REPORTING

5.1 NPDB Report. The Parties acknowledge that an entity making a qualifying payment for the benefit of a licensed health-care practitioner in settlement or satisfaction of a malpractice claim or judgment must report under 42 U.S.C. § 11131 and 45 C.F.R. § 60.7. The payment is to the Claimant, but its reportability turns on whose professional liability is being resolved. [INSURER / SELF-INSURED PAYING ENTITY] shall make any required report to the NPDB and appropriate state licensing board within the period in 45 C.F.R. § 60.5.

5.2 Practitioner's Statement. The reported practitioner may submit a 4,000-character narrative to the NPDB; nothing in this Agreement restricts the practitioner's right to provide such a statement.

5.3 State Reporting. Any reporting required to the Colorado Medical Board, Colorado Board of Nursing, hospital credentialing committees, or other state authority shall not be deemed a breach of this Agreement.

6. HIPAA / MEDICAL RECORDS

6.1 Records. Released Party may retain and use records it lawfully holds only as permitted or required by HIPAA, other applicable law, and the governing retention policy for: (a) defense of related or derivative claims; (b) lien resolution; (c) audit and risk-management; (d) regulatory reporting; and (e) NPDB reporting. This settlement clause is not itself a HIPAA authorization for a covered entity to disclose additional records. Any use or disclosure requiring authorization must rely on a separate authorization valid under 45 C.F.R. § 164.508.

6.2 Return / Destruction. Upon written request after applicable retention periods, originals returned and copies destroyed except as required by law.

7. DISMISSAL OF LITIGATION

7.1 If a civil action has been filed, within [10] business days of receipt of the Settlement Amount, Claimant's counsel shall file a Stipulation of Dismissal With Prejudice under C.R.C.P. 41(a)(1)(B), each Party bearing its own attorney's fees and costs except as expressly provided herein.

8. REPRESENTATIONS AND WARRANTIES

8.1 Claimant represents and warrants: (a) Claimant is the sole owner of the Claim and has not assigned or transferred any portion; (b) Claimant has read this Agreement, consulted with independent counsel of Claimant's choice, and signs voluntarily; (c) Claimant is competent to enter this Agreement; (d) all liens, subrogation claims, and outstanding medical bills identified to Claimant have been disclosed in Exhibit C; (e) Claimant has not filed for bankruptcy, or, if Claimant has, the bankruptcy court has approved this Agreement.

8.2 Released Party represents the Settlement Amount is within available insurance coverage limits and that Insurer is authorized to fund the settlement.

9. MISCELLANEOUS

9.1 Governing Law / Venue. Colorado law governs; venue for any dispute arising hereunder lies in [__] County District Court, Colorado.

9.2 Entire Agreement. This Agreement, with its Exhibits, constitutes the entire agreement and supersedes all prior negotiations.

9.3 Amendment. Only by written instrument signed by both Parties.

9.4 Severability. Invalid provisions severed; remainder enforceable.

9.5 Counterparts; Electronic Signatures. If each Party agrees to conduct this transaction electronically, Colorado UETA applies subject to other law. Electronic form alone is not a reason to deny effect; attribution, authority, consent, delivery, settlement formalities, and other requirements remain.

9.6 Construction. Drafted by counsel for both Parties; no presumption against any Party.

9.7 Notices. Written notice to the addresses set forth above.

10. ACKNOWLEDGMENTS

☐ Claimant has read and understands this Agreement.
☐ Claimant has consulted, or had the opportunity to consult, with independent legal counsel.
☐ Claimant has consulted, or had the opportunity to consult, with an independent tax advisor regarding 26 U.S.C. § 104(a)(2) treatment.
☐ Claimant understands the release is GENERAL and includes unknown claims.
☐ Claimant understands the NPDB report will be filed and cannot be waived.
☐ Claimant has resolved or will resolve all Medicare/Medicaid/ERISA/private liens and indemnifies Released Party.

SIGNATURES

NOTARY ACKNOWLEDGMENT (Claimant)

STATE OF COLORADO ) ss.
COUNTY OF [____] )

Subscribed and sworn before me on [__/__/____] by [CLAIMANT NAME], who is personally known to me or produced [identification].

Notary Public: [____________________]
My commission expires: [__/__/____]

EXHIBITS

• Exhibit A — Structured Settlement Periodic-Payment Schedule (if applicable)
• Exhibit B — Medicare Set-Aside Allocation (if applicable)
• Exhibit C — Disclosed Liens and Outstanding Bills
• Exhibit D — Stipulation of Dismissal With Prejudice
• Exhibit E — Form W-9 / Tax-Identification Forms

Sources and References

• C.R.S. § 13-64-101 et seq. (Health Care Availability Act); § 13-64-302 (damages caps, as amended by 2023 legislation providing graduated annual increases beginning Jan. 1, 2025); § 13-64-205 (periodic payments)
• C.R.S. § 13-21-102.5 (noneconomic-damages limits, generally)
• Colorado POWR Act, C.R.S. § 24-34-407 (NDA limitations)
• 42 U.S.C. § 11131; 45 C.F.R. § 60.7 (NPDB)
• 42 U.S.C. § 1395y(b) (Medicare Secondary Payer); § 1396a(a)(25) (Medicaid recovery)
• 26 U.S.C. § 104(a)(2) (tax exclusion for physical-injury damages); § 130 (qualified assignments)
• 45 C.F.R. Parts 160, 164 (HIPAA)