37 Pa. Code § 171.155
The following is the form for an Election of Jurisdiction:
COMMONWEALTH OF PENNSYLVANIA ARBITRATION PANELS FOR HEALTH CARE
: No.
: County:
: (Form of action)
ELECTION OF JURISDICTION
[] I request that this claim be transferred pursuant to Pa. R.C.P. 213(f) to the Court of Common Pleas of_______ County. This county has venue based on the following facts:
[] Retain this claim with the Arbitration Panels for Health Care for arbitration pursuant to the provisions of the Health Care Services Malpractice Act and the Rules of Practice and Procedure of the Arbitration Panels for Health Care.
I certify that on or before the day of submitting this form to the Administrator, a copy was mailed to or served personally upon all other parties or their counsel.
______________ | ______________ |
Date Signed | Signature |
______________ | ______________ |
If signed by counsel, print | Print Name of Signer |
name of each party represented |
37 Pa. Code § 171.155
This section cited in 37 Pa. Code § 171.7 (relating to Election of Jurisdiction).