Sample Request for Prelitigation Screening Panel

SAMPLE REQUEST FOR PRELITIGATION SCREENING PANEL

NAME OF PETITIONER 1234 EAST 5678 SOUTH SALT LAKE CITY, UT 84121 HOME PHONE: (555) 123-4567 BUSINESS PHONE: (555) 456-7890

THE DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING DEPARTMENT OF COMMERCE, STATE OF UTAH ------JOHN DOE, ) ) REQUEST FOR PRELITIGATION Petitioner, ) SCREENING PANEL ) vs. ) ) RICHARD ROE, M.D. ) ) Respondent. ) Case No. ______

) ------

Pursuant to the provisions of the Utah Health Care Malpractice Act, Title 78B, Chapter 3, Part 4 Utah Code Annotated, 1953, as amended, John Doe hereby requests that the Utah Department of Commerce provide a Prelitigation Panel Review of his medical malpractice claim against the above-named respondent, who is also listed on the Notice of Intent to Commence Action, a true and correct copy of which is attached hereto and incorporated herewith as Exhibit A.

Petitioner has caused a copy of his aforesaid Notice of Intent to Commence Action to be served upon the above-named health care provider on or about the ______day of ______, 200x in accordance with Title 78B, Chapter 3, Part 4 Utah Code Annotated, 1953, as amended. Sixty days or less have elapsed since the service of the aforesaid Notice. Wherefore, petitioner is entitled to make this Request. DATED this ______of ______, 200x.

______Name (petitioner or attorney)