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korea Medical Dispute Mediation and Arbitration Agency

[Easy to Know] How to Prepare Medical Dispute Mediation and Arbitration Application Form 메뉴열기

Dispute Mediation · Arbitration

Application Forms

Mediation Application Forms

No. Name Purpose Download Sample
1 Mediation Application Form (Patient Copy) Patient request for mediation download Preview
2 Annexed Paper to Application Documents for Mediation Detail information about the medical accident download Preview
3 Consent to the Collection, Use, and Processing of Personal Consent to the Collection, Use, and Processing of Personal download
4 Power of Attorney Designate power of attorney on behalf of the patient download
Medical Professional and Organization Copy
No. Name Purpose Download Sample
1 Mediation Application Form (Medical Professional and Organization Copy) Medical professional or organization request for mediation download
2 Annexed Paper to Application Documents for Mediation Detail information about the medical accident
3 Consent to the Collection, Use, and Processing of Personal Consent to the Collection, Use, and Processing of Personal download Preview
4 Power of Attorney(Medical Professional and Organization Copy) Designate power of attorney on behalf of the patient download

Arbitration Application Forms

Patient Copy
No. Name Purpose Download Sample
1 Arbitration Application Form (Patient Copy) Patient request for arbitration download
2 Arbitration Agreement Form Express agreement for arbitration download
3 Annexed Paper to Application Documents for Arbitration Detail information about the medical accident download Preview
4 Consent to the Collection, Use, and Processing of Personal Consent to the Collection, Use, and Processing of Personal download Preview
5 Power of Attorney Designate power of attorney on behalf of the patient download
Medical Professional and Organization Copy
No. Name Purpose Download Sample
1 Arbitration Application Form (Medical Professional and Organization Copy) Medical professional or organization request for arbitration download
2 Arbitration Agreement Form Express agreement for arbitration download
3 Annexed Paper to Application Documents for Arbitration Detail information about the medical accident
4 Consent to the Collection, Use, and Processing of Personal Consent to the Collection, Use, and Processing of Personal download
5 Power of Attorney (Medical Professional and Organization Copy) Designate power of attorney on behalf of the patient download

Other Forms

No. Name Purpose Download Sample
1 Written Appraisal and Reports Application Form Request a review or copy of the written appraisal and other reports download
2 Confirmation of Participation Confirm participation mediation download
3 Written Statement of Response Respond to the request for mediation download
4 Consent for Translation Consent for Translation download
Mediation · Arbitration Fee
Amount requested through mediation · arbitration Fee Notice
Under 5,000,000 KRW 22,000 KRW When you receive refund, we don't make up the loss or profit caused by foreign exchange loss or profit.
Over 5,000,000 KRW
Under 50,000,000 KRW		 22,000 KRW + (over 5,000,000 KRW, add 20 KRW per every 10,000 KRW)
Over 50,000,000 KRW 22,000 KRW + (over 50,000,000 KRW, add 100 KRW per every 10,000 KRW)
Refund Fee Regulations
Reason for Refund Refund Amount
Case rejection Full amount
Case rejection under Article 27 (7) of applicable law Non refundable
Case withdrawal 50%

※ Related Law (Article 27(7))

  • When applicants refuse to participate in the investigation or fail to attend on two occasions.
  • When applicants' actions fall under medical law article 12 (2) or criminal law article 314 (1).
  • When a lawsuit is brought following a mediation request.
Examples of Payment
Amount of mediation-arbitration 1,000,000 KRW 5,000,000 KRW 10,000,000 KRW 50,000,000 KRW 100,000,000 KRW 300,000,000 KRW
Fee 22,000 22,000 32,000 112,000 162,000 362,000