"NOTICE:
Dr. _______________ (here state the full name of the license holder) is not covered by medical malpractice insurance.
The undersigned acknowledges the receipt of this notice.
_____________________________(Patient's Signature)_____________________________(Date)"
The license holder shall obtain the patient's signature, acknowledging the patient's receipt of the notice, prior to providing nonemergency professional services to the patient. The license holder shall maintain the signed notice in the patient's medical record.
This section does not apply to a person who complies with division (B)(2) of section 2305.234 of the Revised Code.
R.C. § 4731.143