Common use of Retroactive Effect Clause in Contracts

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. . Effective as the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: DATE:

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. . Effective as the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: DATE:SIGNATURE (OR PATIENT REPRESENTATIVE)

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) ), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATUREName: DATESignature:

Retroactive Effect. If patient Patient intends this agreement to cover services rendered before the date it is signed (for exampleincluding, but not limited to, emergency treatment) patient should initial here. . Effective effective as of the date of first professional medical services. If any provision of this Arbitration Agreement arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a the copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copyarbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 ONE OF THIS CONTRACT. PATIENT SIGNATUREBY: DATE:XXXXX XXXX, MD, PC Patient’s or Patient Representative’s Signature Date

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) ), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIALAs a patient at Seasons of Balance Family Acupuncture, I have read, understand, and agree to the Arbitration Agreement as stated above. SEE ARTICLE By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See Article 1 OF THIS CONTRACTof this contract. PATIENT SIGNATURE: DATE:Patient Name (print):

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for exampleincluding, but not limited to, emergency treatment) patient ), Patient should initial here. . below: Effective as of the date of first professional medical services. : Patient Initials If any provision of if this Arbitration Agreement arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreementarbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: DATE:Signature Authorized Provider Representative

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. . Effective as of the date of first professional medical services. If any provision of if this Arbitration Agreement arbitration agreement is held invalid or of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreementarbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: DATECONTRACT Patient Name (Print): Date of Birth:

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. here . Effective as the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: SIGNATURE DATE:

Retroactive Effect. If the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT' S FULL NAME PATIENT SIGNATURE: / GUARDIAN' S SIGNATURE DATE:

Retroactive Effect. If the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here. here . Effective as the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received and/or been offered a copycopy of this agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: DATE:.

Retroactive Effect. If patient Patient intends this agreement to cover services rendered before the date it is signed (for exampleincluding, but not limited to, emergency treatment) patient should initial here. . Effective effective as of the date of first professional medical services. If any provision of this Arbitration Agreement arbitration agreement is held invalid or unenforceable, the remaining remainin g provisions shall remain in full ful l force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a the copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copyarbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY BINDING NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE (REFER TO ARTICLE 1 ONE OF THIS CONTRACT). PATIENT SIGNATUREBY: DATE:XXXXX XXXX, MD, PC _ _ _ _ _ _ _ _ _ _ _ _ Patient’s or Patient Representative’s Signature Date

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) ), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIALAs a patient at Seasons of Balance Family Acupuncture, I have read, understand, and agree to the Arbitration Agreement as stated above. SEE ARTICLE By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See Article 1 OF THIS CONTRACTof this contract. PATIENT SIGNATURE: DATE:Patient Name (print) Signature Date

Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) ), patient should initial here. . Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: DATE:.