Medical Malpractice Settlement Agreement and Mutual Release (Wyoming)

MEDICAL MALPRACTICE SETTLEMENT AGREEMENT AND MUTUAL RELEASE

(Wyoming)

1. PARTIES AND RECITALS

1.1 Parties. This Medical Malpractice Settlement Agreement and Mutual Release (the "Agreement") is entered into and effective as of [__/__/____] (the "Effective Date") between:

If Claimant is a minor, incapacitated, or deceased, [GUARDIAN / CONSERVATOR / PERSONAL REPRESENTATIVE NAME] signs in such representative capacity, with court approval as required under Wyo. Stat. § 1-38-102 (wrongful death) or applicable probate/guardianship statute.

1.2 Recitals.

A. Claimant alleges that on or about [DATE(S) OF CARE], Released Provider's medical services at [FACILITY / LOCATION] caused injury (the "Claim"), described in Exhibit A.
B. The Claim is or may be the subject of an action styled [CASE CAPTION], [☐ filed ☐ to be filed] in the District Court for [______] County, Wyoming (the "Action").
C. The Parties wish to fully and finally compromise the Claim without admission of liability.

1.3 No Admission of Liability. This Agreement is a compromise. Released Provider expressly denies negligence, fault, or wrongdoing.

2. SETTLEMENT CONSIDERATION

2.1 Settlement Sum. Released Provider/Insurer shall pay Claimant $[__________] (the "Settlement Sum") in full and final settlement.

2.2 Allocation.

2.3 Payment Terms. Payable within [30] days of: (a) full execution of this Agreement; (b) court approval if required (minor, decedent, incapacitated); and (c) Claimant's delivery of lien satisfactions or escrow arrangements per Section 5.

2.4 Structured Settlement (Optional). ☐ A portion of the Settlement Sum, $[______], shall be funded by a qualified assignment under IRC § 130 with annuity provider [NAME]; terms in Exhibit B.

3. RELEASE

3.1 General Release. Claimant, on behalf of Claimant and Claimant's heirs, executors, administrators, successors, and assigns, RELEASES and FOREVER DISCHARGES Released Provider, its affiliates, officers, directors, employees, agents, insurers, and reinsurers from any and all claims, demands, causes of action, damages, costs, and expenses, known or unknown, suspected or unsuspected, arising from or related to the care described in Exhibit A.

3.2 Unknown Claims. Claimant expressly waives any right under any statute or common-law rule that would preserve claims unknown at signing.

3.3 Carve-Outs. This release does NOT extend to:

☐ Obligations created by this Agreement
☐ Workers' compensation rights, if any
☐ Claims against any non-party not expressly named

4. WRONGFUL DEATH / SURVIVAL (IF APPLICABLE)

☐ Claimant is the duly appointed Personal Representative in [Case No., Probate Court] with authority to settle.
☐ Settlement allocation among statutory beneficiaries is set forth in Exhibit C and is subject to district court approval under Wyo. Stat. § 1-38-102.

5. LIENS, SUBROGATION, AND COLLATERAL SOURCES

5.1 Claimant Responsibility. Claimant shall satisfy or hold in escrow all liens and subrogation interests, including:

☐ Medicare (42 U.S.C. § 1395y(b)(2) — Conditional Payment / MSP)
☐ Medicaid (42 U.S.C. § 1396k; Wyoming Medicaid recovery)
☐ ERISA health-plan reimbursement
☐ Tricare / VA
☐ Hospital and provider liens
☐ Workers' compensation subrogation, if any

5.2 Medicare Set-Aside (MSA). ☐ Not applicable. ☐ MSA prepared by [VENDOR] in the amount of $[______], administered as set forth in Exhibit D, to protect Medicare's interest in future medicals.

5.3 Claimant Indemnity. Claimant shall indemnify Released Provider and Insurer against any lien, subrogation, or reimbursement claim arising out of the Claim, up to the Settlement Sum.

6. NPDB REPORTING

6.1 Acknowledgment. The Parties acknowledge that payment in settlement of a written claim against a licensed practitioner must be reported to the National Practitioner Data Bank under 45 C.F.R. Part 60. Released Provider/Insurer shall make the report; the Parties shall cooperate to ensure factual accuracy.

6.2 No Waiver. Nothing in this Agreement requires either Party to omit, falsify, or alter required reporting to the NPDB, the Wyoming Board of Medicine, the Wyoming Board of Nursing, CMS, or any other regulator.

7. CONFIDENTIALITY AND NON-DISPARAGEMENT

7.1 Confidentiality. Except as required by law or court order, the Parties shall keep confidential the amount and terms of this Agreement. Permitted disclosures include:

☐ Counsel, accountants, tax advisors, and immediate family on a need-to-know basis
☐ Lien holders and government payors
☐ The NPDB and licensing boards
☐ Court-required filings (e.g., minor's compromise, wrongful-death approval)

7.2 Non-Disparagement. Neither Party shall make public statements disparaging the other regarding the Claim. Truthful statements to regulators, in legal proceedings, or required by law are not breaches.

7.3 Liquidated Damages. Material breach of Section 7.1 by Claimant entitles Released Provider to liquidated damages of $[______] per disclosure, the Parties agreeing this amount is a reasonable estimate of harm.

8. TAX TREATMENT

8.1 IRC § 104(a)(2). The Parties intend that amounts allocated to compensate for personal physical injury or physical sickness be excludable from gross income under 26 U.S.C. § 104(a)(2). Amounts allocated to lost wages, punitive damages, or interest may be taxable. Each Party is responsible for its own tax determinations; no Party provides tax advice.

8.2 Form 1099 Reporting. Reporting shall comply with IRS rules; Claimant shall furnish a completed Form W-9.

9. GOVERNMENTAL CLAIMS ACT (IF APPLICABLE)

☐ Not applicable — Released Provider is a private entity.
☐ Applicable — Notice of claim under Wyo. Stat. § 1-39-113 was timely served on [__/__/____]; this settlement complies with Wyo. Stat. § 1-39-118 caps and governmental approval requirements.

10. DISMISSAL OF ACTION

Within [14] days after Claimant's receipt of the Settlement Sum, the Parties shall file a Stipulation of Dismissal With Prejudice in the Action, each Party to bear its own remaining costs and attorneys' fees except as provided herein.

11. REPRESENTATIONS AND WARRANTIES

Each Party represents that: (a) it has authority to enter this Agreement; (b) it has consulted independent counsel or knowingly waived such consultation; (c) it is not relying on representations outside this Agreement; and (d) no claim has been assigned to any third party.

12. DISPUTE RESOLUTION

12.1 Governing Law. Wyoming law governs.
12.2 Venue. Exclusive venue in the District Court for [______] County, Wyoming.
12.3 Attorneys' Fees. Prevailing Party in any enforcement action recovers reasonable fees and costs.

13. GENERAL PROVISIONS

13.1 Entire Agreement. Supersedes all prior negotiations and writings.
13.2 Amendment. Only by writing signed by both Parties.
13.3 Severability. Invalid provisions severed; remainder enforceable.
13.4 Counterparts; E-Signatures. Permitted under Wyo. Stat. § 40-21-101 et seq.
13.5 Construction. This Agreement is the joint product of the Parties; no presumption against the drafter.

14. EXECUTION

Acknowledgment (Notary):
State of Wyoming, County of [______] — Subscribed and sworn before me on [__/__/____] by [NAME].
______________________________ Notary Public; My commission expires: [__/__/____].

EXHIBITS

• Exhibit A — Description of the Claim / Care at Issue
• Exhibit B — Structured Settlement Terms (if any)
• Exhibit C — Wrongful-Death Beneficiary Allocation (if any)
• Exhibit D — Medicare Set-Aside Documentation (if any)

SOURCES AND REFERENCES

• Wyo. Const. art. 10, § 4(a)
• Wyo. Stat. § 1-3-107 (med-mal statute of limitations)
• Wyo. Stat. § 1-38-101 et seq. (Wrongful Death)
• Wyo. Stat. § 1-39-101 et seq. (Governmental Claims Act)
• 2021 Wyo. Sess. Laws ch. 99 (repealing Medical Review Panel effective 7/1/2022)
• 45 C.F.R. Part 60 (NPDB)
• 42 U.S.C. § 1395y(b)(2) (Medicare Secondary Payer)
• 26 U.S.C. § 104(a)(2)
• Wyoming Board of Medicine, https://wybom.wyo.gov