Court Opinion

ID: 4655518
Source: CourtListenerOpinion
Date Created: 2021-01-28 19:02:52.851872+00
Date Added: 2024-06-11T08:00:19.919274
License: Public Domain

The summaries of the Colorado Court of Appeals published opinions
  constitute no part of the opinion of the division but have been prepared by
  the division for the convenience of the reader. The summaries may not be
    cited or relied upon as they are not the official language of the division.
  Any discrepancy between the language in the summary and in the opinion
           should be resolved in favor of the language in the opinion.

                                                                  SUMMARY
                                                            January 28, 2021

                                 2021COA7

No. 19CA1211, Johnson v Rowan Inc — Health and Welfare —

Health Care Availability Act — Agreement for Medical Services;

ADR — Arbitration

     A division of the court of appeals considers for the first time

whether a health care provider substantially complies with

section 13-64-403, C.R.S. 2020, of the Health Care Availability Act

if it (1) fails to provide a patient with a written copy of an arbitration

agreement that the patient has signed or (2) itself fails to sign the

arbitration agreement. Applying the supreme court’s analysis in

Colorow Health Care LLC v. Fischer, 2018 CO 52M, 420 P.3d 259,

the division concludes that a health care provider that either does

not provide the written copy of the arbitration agreement to the

patient or does not sign it fails to substantially comply with the Act
and, as a consequence, its arbitration agreement is unenforceable

against the patient.
COLORADO COURT OF APPEALS                                            2021COA7

Court of Appeals No. 19CA1211
City and County of Denver District Court No. 18CV33463
Honorable Ross B. Buchanan, Judge

Patricia Johnson, individually and as heir at law of Christal Johnson,
deceased; and Randall Johnson, individually and as heir at law of Christal
Johnson, deceased,

Plaintiffs-Appellees,

v.

Rowan Incorporated, a Colorado corporation; Jay Moskowitz; and QP Health
Care Services LLC,

Defendants-Appellants.

                              ORDER AFFIRMED

                                  Division VI
                          Opinion by JUDGE LIPINSKY
                        Pawar and Martinez*, JJ., concur

                         Announced January 28, 2021

Law Offices of J.M. Reinan, P.C., Jerome M. Reinan, Jordana Griff Gingrass,
Denver, Colorado, for Plaintiffs-Appellees

Messner Reeves LLP, Kendra N. Beckwith, Doug C. Wolanske, Mary Byrne
Fletcher, Elizabeth K. Slinas-Van Orman, Denver, Colorado, for Defendants-
Appellants

Levin Sitcoff, PC, Nelson Waneka, Dener, Colorado, for Amicus Curiae Colorado
Trial Lawyers Association

*Sitting by assignment of the Chief Justice under provisions of Colo. Const. art.
VI, § 5(3), and § 24-51-1105, C.R.S. 2020.
¶1    Randall and Patricia Johnson were handed a stack of forms

 when they admitted their seriously ill adult daughter, Christal, to

 Rowan Community, a long-term care facility. The Johnsons signed

 a number of those documents that day at the request of Rowan

 Community’s social services director. One of those documents was

 an arbitration agreement (the agreement).

¶2    Following Christal’s death less than two months later, the

 Johnsons, individually and as Christal’s heirs, sued Rowan

 Community’s owner — Rowan Incorporated — and two other

 defendants — Jay Moskowitz and QP Health Care Services LLC

 (collectively, Rowan) for wrongful death, among other causes of

 action. Rowan moved to compel arbitration based on the language

 of the agreement. The Johnsons argued that the agreement was

 unenforceable for two reasons — because a Rowan Community

 representative had not countersigned it and because Rowan

 Community had allegedly not provided them with a written copy of

 the agreement, in violation of provisions of the Health Care

 Availability Act (the Act), §§ 13-64-101 to -503, C.R.S. 2020. In a

 written order, the district court agreed with the Johnsons and held

                                   1
 that the agreement was unenforceable. Rowan filed this

 interlocutory appeal.

¶3    We decide that, under the Act, Rowan Community cannot

 enforce the agreement because it did not substantially comply with

 the Act’s requirements that a health care provider (1) give the

 patient a written copy of any arbitration agreement he or she signs

 and (2) itself sign the arbitration agreement. For these reasons, we

 affirm the district court’s order.

                            I.    Background

¶4    Christal Johnson had a brain tumor and other serious health

 conditions. The Johnsons decided to place Christal in a long-term

 care facility when they were no longer able to care for her on their

 own. The Johnsons selected Rowan Community, a skilled nursing

 facility, to provide their daughter with round-the-clock care.

¶5    On the day of Christal’s arrival at Rowan Community, the

 Johnsons met with Rowan Community’s social services director,

 Tammy Gleisner, to complete the admission process. Gleisner

 presented the Johnsons with what Mr. Johnson described as an

 “inch-and-a-half worth of papers” for them to sign as Christal’s legal

 representatives. Either or both of the Johnsons signed the

                                      2
 documents, including the agreement, during their meeting with

 Gleisner. Neither Gleisner nor any other representative of Rowan

 Community signed the agreement, however. In addition, the

 district court found that Gleisner did not provide the Johnsons with

 a written copy of the agreement.

¶6    Christal was hospitalized three times shortly after her

 admission to Rowan Community. She died during the third

 hospitalization.

¶7    The Johnsons filed suit against Rowan Community’s corporate

 owner, its management company, and those companies’ individual

 owner, manager, and operator for negligence resulting in wrongful

 death, violation of the Colorado Consumer Protection Act, fraud and

 fraudulent nondisclosure, and civil conspiracy.

¶8    Rowan’s attorneys informed counsel for the Johnsons that the

 Johnsons had signed the agreement at the time Christal was

 admitted to Rowan Community and provided a written copy of the

 agreement to the Johnsons’ counsel. The copy of the agreement

 provided to the Johnsons contained Mr. Johnson’s signature, but

 was missing the signature of a representative of Rowan Community.

 The Johnsons asserted that they had not seen the agreement

                                    3
  before. Through their counsel, the Johnsons attempted to exercise

  their right to rescind the agreement pursuant to the agreement’s

  rescission clause. Rowan responded that the Johnsons had waited

  too long to rescind the agreement and were therefore bound by its

  terms.

¶9     Rowan moved to stay the Johnsons’ case and compel

  arbitration based on the terms of the agreement.

¶ 10   The district court conducted an evidentiary hearing at which

  Mr. Johnson and Gleisner testified. Mr. Johnson testified that he

  did not recall discussing the agreement with Gleisner, signing it, or

  receiving a written copy of it, and that he had not intended to waive

  his and his wife’s right to a jury trial. Gleisner testified that she

  discussed the agreement with the Johnsons and that her failure to

  sign the agreement was “an oversight.”

¶ 11   Following the hearing, the district court entered an order

  denying Rowan’s motion. After finding that Mr. Johnson was more

  credible than Gleisner, the court further found that Rowan

  Community had not provided the Johnsons with a written copy of

  the agreement. After considering the supreme court’s analysis of

  the Act in Colorow Health Care, LLC v. Fischer, 2018 CO 52M, 420

                                      4
  P.3d 259, the court concluded that, because Rowan Community

  failed to sign the agreement and provide a written copy of the

  agreement to the Johnsons, “the Agreement does not substantially

  comply with [the] statutory requirements of C.R.S. § 13-64-403,

  [C.R.S. 2020] and thus, . . . is invalid.”

¶ 12   The district court distinguished the requirements of the Act

  that the health care provider sign and provide a written copy of the

  arbitration agreement to the patient from the requirement of the Act

  at issue in Colorow — that health care arbitration agreements

  contain, in bold-faced text, a statement disclosing to the patient

  that, by signing the agreement, she is waiving the right to have any

  issue of medical malpractice decided by a jury or court trial. (The

  parties do not dispute that the Act’s references to “patient” include

  authorized patient representatives, such as Mr. Johnson, who sign

  a health care arbitration agreement on behalf of the patient. For

  this reason, in this opinion we do not distinguish between patients

  and the authorized patient representatives who sign arbitration

  agreements on behalf of the patients.)

¶ 13   The district court held that, in contrast to the health care

  provider’s minimal noncompliance with the Act’s typeface

                                      5
  requirement at issue in Colorow, Rowan Community had failed to

  substantially comply with the Act by neither signing the agreement

  nor providing a written copy of the agreement to the Johnsons.

  Applying the substantial compliance standard, the district court

  held that Rowan Community’s failure to comply with the Act

  adversely affected the Johnsons’ ability to exercise their statutory

  right to rescind the agreement and thus rendered the agreement

  unenforceable.

¶ 14   Rowan filed this interlocutory appeal pursuant to section

  13-22-228(1)(a), C.R.S. 2020.

                             II.   Discussion

¶ 15   Rowan challenges only the district court’s legal conclusion and

  not its factual findings. Thus, we accept the district court’s findings

  of fact and limit our review to the legal issue of whether the

  agreement complied with the Act and, therefore, is enforceable

  against the Johnsons.

               A.    Jurisdiction and Standard of Review

¶ 16   “An order denying a motion to compel arbitration is

  immediately appealable.” Lujan v. Life Care Ctrs. of Am., 222 P.3d

  970, 972 (Colo. App. 2009); see § 13-22-228(1)(a). We review issues

                                     6
  of statutory construction de novo. Colorow, ¶ 10, 420 P.3d at

  261-62. Specifically, “[w]e review de novo the district court’s

  decision on a motion to compel arbitration, employing the same

  legal standards that the district court employed.” Lujan, 222 P.3d

  at 972 (citing Moffett v. Life Care Ctrs. of Am., 187 P.3d 1140, 1143

  (Colo. App. 2008)).

        B.    Colorow and the Substantial Compliance Standard
                   for Arbitration Agreements Under the Act

¶ 17   “Arbitration is favored in Colorado as a convenient and

  efficient alternative to resolving disputes by litigation. A valid and

  enforceable arbitration provision divests the court of jurisdiction

  over all arbitrable issues.” Vallagio at Inverness Residential Condo.

  Ass’n v. Metro. Homes, Inc., 2015 COA 65, ¶ 13, 412 P.3d 709, 713

  (citation omitted), aff’d, 2017 CO 69, 395 P.3d 788. A court “may

  refuse to compel arbitration ‘only upon a showing that there is no

  agreement to arbitrate or if the issue sought to be arbitrated is

  clearly beyond the scope of the arbitration provision.’” Id. at ¶ 14,

  412 P.3d at 713 (quoting Eychner v. Van Vleet, 870 P.2d 486, 489

  (Colo. App. 1993)).

                                     7
¶ 18   Section 13-64-403 of the Act sets forth the requirements for

  arbitration agreements between health care providers and their

  patients. The Act addresses two principal policy objectives

  concerning such arbitration agreements. First, the Act generally

  “assure[s] the continued availability of adequate health care

  services . . . by containing the significantly increasing costs of

  malpractice insurance for medical care institutions.”

  § 13-64-102(1), C.R.S. 2020. Second, while authorizing agreements

  to arbitrate health care disputes to accomplish this general

  purpose, section 13-64-403 also requires that such agreements be

  voluntary and “contain[] protective provisions [to] curb[] abusive

  practices in obtaining agreements to arbitrate.” Moffett v. Life Care

  Ctrs. of Am., 219 P.3d 1068, 1073 (Colo. 2009); see § 13-64-403(1).

¶ 19   To ensure that a patient enters into a health care arbitration

  agreement voluntarily, section 13-64-403 sets forth several

  requirements for arbitration agreements between health care

  providers and their patients. Three of these requirements are

  germane to the resolution of this appeal.

¶ 20   First, a health care arbitration agreement

                                     8
               shall have the following statement set forth as
               part of the agreement: “. . . The patient has the
               right to seek legal counsel concerning this
               agreement, and has the right to rescind this
               agreement by written notice to the physician
               within ninety days after the agreement has
               been signed and executed by both parties
               unless said agreement was signed in
               contemplation of the patient being
               hospitalized, in which case the agreement may
               be rescinded by written notice to the physician
               within ninety days after release or discharge
               from the hospital or other health care
               institution. . . .”

  § 13-64-403(3). (The district court found that the agreement was

  not signed in contemplation of Christal being hospitalized. As

  noted above, Rowan does not challenge the court’s findings of fact.)

¶ 21      Second, the required disclosure statement must be printed in

  “at least ten-point bold-faced type” immediately above the

  agreement’s signature lines. The statement must read, in relevant

  part:

               NOTE: BY SIGNING THIS AGREEMENT YOU
               ARE AGREEING TO HAVE ANY ISSUE OF
               MEDICAL MALPRACTICE DECIDED BY
               NEUTRAL BINDING ARBITRATION RATHER
               THAN BY A JURY OR COURT TRIAL.

               YOU HAVE THE RIGHT TO SEEK LEGAL
               COUNSEL AND YOU HAVE THE RIGHT TO
               RESCIND THIS AGREEMENT WITHIN
               NINETY DAYS FROM THE DATE OF

                                       9
             SIGNATURE BY BOTH PARTIES UNLESS
             THE AGREEMENT WAS SIGNED IN
             CONTEMPLATION OF HOSPITALIZATION IN
             WHICH CASE YOU HAVE NINETY DAYS
             AFTER DISCHARGE OR RELEASE FROM
             THE HOSPITAL TO RESCIND THE
             AGREEMENT.

  § 13-64-403(4).

¶ 22   Third, “[t]he patient shall be provided with a written copy of

  any agreement subject to the provisions of this section at the time

  that it is signed by the parties.” § 13-64-403(6).

¶ 23   A health care provider may not condition the provision of

  medical care services or emergency medical services on a patient’s

  failure or refusal to sign such an agreement or exercise of the

  statutory ninety-day right of rescission. § 13-64-403(7)-(8).

¶ 24   These provisions grant the patient a period of time to reflect on

  the implications of waiving the right to have a judge or jury hear

  any malpractice case against the health care provider. Further, the

  provisions give the patient the ability to review the arbitration

  agreement with legal counsel and, if she chooses, to exercise the

  right of rescission. A provider’s failure to comply with these

  provisions of the Act “render[s] the [arbitration] agreement

  unenforceable.” Allen v. Pacheco, 71 P.3d 375, 381 (Colo. 2003).

                                    10
¶ 25   In Colorow, in the course of discussing section 13-64-403(4)’s

  typeface requirement, the Colorado Supreme Court broadly held

  that health care providers need only substantially comply with the

  Act. Although the arbitration agreement at issue in Colorow

  included the required language, the section 13-64-403(4) disclosure

  statement was printed in regular “twelve-point type and all capital

  letters,” rather than in “bold-faced . . . font.” Colorow, ¶¶ 6, 28, 420

  P.3d at 261, 264. The patient’s family contended that the variance

  from the typeface requirement rendered the agreement

  unenforceable.

¶ 26   The Colorow court first decided whether an arbitration

  agreement must strictly comply, or only substantially comply, with

  the Act to be enforceable. After determining that the text of the Act

  did not shed light on the required level of compliance, the court

  considered which standard best “effectuates the General Assembly’s

  purpose in enacting the [Act].” Id. at ¶ 27, 420 P.3d at 264.

¶ 27   The court first noted that the purpose of the typeface

  requirement is to “emphasize the required language. Emphasizing

  this text encourages patients to read it and understand its

  importance.” Id. at ¶ 28, 420 P.3d at 264. Significantly for our

                                    11
  analysis, the court said that, “[w]hile bold-faced text and minimum

  print size are ways to draw attention to the advisement, there are

  other — sometimes better — ways to do so,” such as highlighting

  the language or placing it in all capital letters. Id. at ¶ 29, 420 P.3d

  at 264. And, as the court pointed out, depending on the particular

  font used, “strict compliance might nonetheless fail to draw

  attention to the voluntariness language.” Id.

¶ 28   Concluding that the General Assembly did not “intend[] to

  elevate form over function,” the court held that the purpose of the

  typeface requirement — to conspicuously disclose important

  information to the patient — “is better served by the flexibility

  substantial compliance affords.” Id. at ¶ 30, 420 P.3d at 265.

¶ 29   The court then “examine[d] the general purpose animating the

  [Act] as a whole: keeping insurance costs low for medical providers.”

  Id. at ¶ 31, 420 P.3d at 265. It held that this purpose was

  supported by the application of a substantial, rather than a strict,

  compliance standard to the typeface requirement, which would

  “send the right issues to court.” Id. at ¶ 34, 420 P.3d at 266.

  Under substantial compliance,

                                     12
            agreements with only minor technical
            deficiencies — those that don’t bear on
            voluntariness in any material sense — will
            keep parties in arbitration and avoid the costs
            of full-blown merits litigation. A party seeking
            to litigate the merits will have a colorable
            substantial-compliance issue to litigate only
            when an arbitration agreement suffers more
            serious deficiencies — those that could
            actually bear on voluntariness.

  Id. Thus, “[p]unishing health care providers for minor

  typographical deficiencies that don’t affect voluntariness wouldn’t

  serve . . . the Act’s purposes.” Id. at ¶ 35, 420 P.3d at 266. But

  where “more significant deficiencies . . . might affect voluntariness,

  punishing providers for failure to substantially comply would

  further the statute’s purpose of ensuring voluntariness.” Id.

¶ 30   For these reasons, the court concluded that “a

  substantial-compliance standard is consistent with the general

  purpose of the [Act], and the specific purpose of the typeface

  requirements set forth in section 13-64-403.” Id. at ¶ 37, 420 P.3d

  at 266.

¶ 31   After deciding to apply a substantial compliance standard, the

  court considered whether the arbitration agreement at issue

  substantially complied with the Act’s typeface requirement. To

                                    13
  answer this question, the court applied the test for substantial

  compliance announced in Bickel v. City of Boulder, 885 P.2d 215

  (Colo. 1994). Bickel teaches that, when deciding whether a party

  has substantially complied with constitutional or statutory

  requirements, a court should

                consider factors including, but not limited to,
                the following: (1) the extent of the [party’s]
                noncompliance [with the requirements], (2) the
                purpose of the provision violated and whether
                that purpose is substantially achieved despite
                the [party’s] noncompliance, and (3) whether it
                can reasonably be inferred that the [party]
                made a good faith effort to comply or whether
                the [party’s] noncompliance is more properly
                viewed as the product of an intent to mislead.

  Id. at 227.

¶ 32   In applying the first Bickel factor, the Colorow court held that

  the facility’s noncompliance with the typeface requirement was

  “minimal.” Colorow, ¶ 40, 420 P.3d at 267. The required language

  was present, separated from the rest of the text, in all capital

  letters, and in a larger font than required. Id. As to the second

  factor, the court held that “the purpose behind section 13-64-403

  — voluntariness — is achieved despite the technical

  noncompliance.” Id. at ¶ 41, 420 P.3d at 267. The arbitration

                                      14
  agreement at issue included the required disclosure language, and

  there was no evidence that the patient’s representative had been

  coerced into signing the agreement. Id.

¶ 33   Finally, in considering the third factor, the court held that “it

  can reasonably be inferred that the Facility made a good faith effort

  to comply with the statute,” as evidenced by the fact that the

  required text was set apart from the rest of the language of the

  arbitration agreement. Id. at ¶ 42, 420 P.3d at 267. The court

  “perceive[d] no effort to mislead, such as by burying the required

  text in fine print or by using a type of script that is unusually

  difficult to read.” Id.

¶ 34   Thus, the court held that, despite the facility’s technical

  noncompliance with the typeface requirement of the Act, it

  nonetheless substantially complied with the requirement, rendering

  the agreement enforceable. Id. at ¶ 43, 420 P.3d at 267.

  C.    The District Court Did Not Err by Finding That the Agreement
                      Was Unenforceable Under the Act

¶ 35   As explained below, the agreement here is unenforceable

  under the more lenient substantial compliance standard. For this

  reason, and because Colorow broadly held that providers need only

                                    15
  substantially comply with the Act, we do not discuss strict

  compliance in this case. If Rowan Community did not substantially

  comply with the Act by failing to give the Johnsons a fully signed

  and executed copy of the agreement, it could not have strictly

  complied with the relevant provisions of the Act.

   1.    Rowan Community’s Failure to Provide the Johnsons with a
                   Written Copy of the Agreement

¶ 36    The district court found that Rowan Community’s

  representative did not provide the Johnsons with a written copy of

  the agreement after Mr. Johnson signed it during the process of

  admitting Christal to Rowan Community. According to the district

  court, the Johnsons did not receive a written copy of the agreement

  until they obtained one from Rowan’s attorneys after initiating this

  litigation.

¶ 37    The district court applied the Bickel factors to find that Rowan

  Community did not substantially comply with the “written copy”

  requirement set forth in section 13-64-403(6).

¶ 38    In analyzing the first Bickel factor, the court held that Rowan

  Community’s “noncompliance is not minimal; [it] violated a direct

                                    16
  provision of the statute by failing to provide [the Johnsons with] a

  copy of the Agreement ‘signed by the parties.’” § 13-64-403(6).

¶ 39   The court determined that, under the second Bickel factor,

  Rowan Community’s failure to provide the Johnsons with a written

  copy of the agreement “directly circumvent[ed]” a material purpose

  of the Act — to protect patients from “unknowingly and

  involuntarily waiving their rights to sue in court.” Colo. Permanente

  Med. Grp., P.C. v. Evans, 926 P.2d 1218, 1232 (Colo. 1996). In

  addition, the court said that, “[w]ithout a copy of the written

  Agreement, [the Johnsons] were unable to fully exercise their ‘right

  to seek legal counsel concerning this agreement’ by not being able

  to show legal counsel the Agreement, and were unable [to] fully

  understand their right to rescind the Agreement.” The Act’s

  disclosure requirements and right to confer with counsel regarding

  an arbitration agreement are “important mechanisms” to protect

  patients from involuntarily giving up their right to bring their claims

  before a court and a jury.

¶ 40   Because Rowan Community did not give the Johnsons a

  written copy of the agreement, the court reasoned that they “were

  deprived of the opportunity to review the Agreement, a complex

                                    17
  document with statutory notices that can be problematic for lay

  people to understand in the best of circumstances, at their own

  pace and outside the stressful environment of an intake meeting for

  their sick daughter.”

¶ 41   Regarding the third factor, while the court found “no evidence

  of an intent to mislead,” or that Rowan Community acted in bad

  faith, it could not find that Rowan Community made a good faith

  effort to comply with the Act’s requirement that the patient be

  provided with a written copy of the arbitration agreement “because

  it did not ensure that [the Johnsons] received a copy of the

  Agreement.” Rather, “the Agreement was buried in a stack of

  papers” that Gleisner instructed the Johnsons to read and sign “in

  a relatively short period of time.”

¶ 42   The district court correctly determined that Rowan

  Community did not substantially comply with the Act’s “written

  copy” requirement. Rowan Community’s noncompliance with this

  requirement was not minimal because it failed to provide the

  Johnsons with a written copy of the agreement until after the

  Johnsons filed suit. Provision of a signed arbitration agreement to

  the patient is integral to the Act’s purpose of ensuring that the

                                        18
  patient enters into a health care arbitration agreement voluntarily.

  Unless she receives a written copy of the arbitration agreement she

  signed, in many circumstances, the patient would be unable to

  review that agreement’s language in a stress-free setting, discuss it

  with an attorney, or contemplate the significance of waiving the

  right to a jury or court trial. As a result, she may not even be aware

  of her right to seek legal advice regarding the consequences of

  agreeing to arbitrate and her right to rescind the agreement if she

  decides, upon reflection, that she does not wish to consent to

  arbitration. Moreover, without a written copy of the arbitration

  agreement, the patient may not know how or when she can exercise

  the right to rescind.

¶ 43   In this case, the district court specifically found that the

  Johnsons “were deprived of the opportunity to review the

  Agreement” after admitting their daughter to Rowan Community

  and were not aware of its terms. Even if Rowan Community did not

  act in bad faith by failing to provide the Johnsons with a written

  copy of the agreement, the Johnsons lacked a meaningful

  opportunity to consider the significance of waiving their right to a

  jury or court trial and, if they decided upon reflection they did not

                                    19
  wish to consent to arbitration, to exercise their right to rescind the

  agreement. Thus, even if Rowan Community acted in good faith,

  that good faith alone would not make up for its noncompliance with

  the “written copy” requirement of section 13-64-403(6).

¶ 44   Rowan notes that, in Colorow, the supreme court held that the

  health care provider substantially complied with the Act, even

  though it had indisputably violated the provision of the Act

  mandating that the required disclosure statement appear in

  bold-faced type. But there is a material distinction between a

  provider’s use of an incorrect typeface in an arbitration agreement

  and its failure to provide the patient with a written copy of the

  agreement. Unlike the former noncompliance with the Act’s

  requirements, the latter noncompliance is more likely to be material

  to the issue of voluntariness and may have a direct bearing on the

  patient’s ability to understand the significance of waiving the right

  to a jury or court trial, to consider whether waiving such right is in

  her best interest, and, if she decides upon reflection not to

  arbitrate, to exercise her right of rescission. The failure to give a

  patient a written copy of an arbitration agreement will often be a

                                     20
  “more significant deficienc[y]” than the “minor typographical” error

  in Colorow. Colorow, ¶ 35, 420 P.3d at 266.

¶ 45   As Colorow made clear, while “strict consistency isn’t the

  objective[,] [v]oluntariness is.” Id. at ¶ 36, 420 P.3d at 266. Here,

  the voluntariness of the Johnsons’ agreement to waive their right to

  a jury or court trial was not safeguarded because they lacked a

  written copy of the document they needed — in any typeface — to

  make a substantive decision about arbitration and exercising their

  statutory right to rescind.

¶ 46   Moreover, the absence of a meaningful alternative to the

  provision of a written copy of the arbitration agreement to the

  patient distinguishes the Johnsons’ case from Colorow. Rowan

  does not offer any alternative to providing the patient with a written

  copy of an arbitration agreement, as section 13-64-403(6) requires.

  Instead, Rowan suggests that, following Christal’s admission, the

  Johnsons could have called Rowan Community to request a written

  copy of the agreement.

¶ 47   The supreme court’s decision in Colorow rested on its

  conclusion that there was a meaningful alternative to the Act’s

  typeface requirement that furthered that subsection’s purpose of

                                    21
  providing notice. See Colorow, ¶ 29, 420 P.3d 264-65. The court

  determined that the purpose of the Act’s bold-faced type

  requirement — to “emphasize the required language” and

  “encourage[] patients to read it and understand its

  importance” — could be accomplished by other means, such as

  “[h]ighlighting the text in a particular color, underlining it, [or]

  printing it in all capital letters . . . .” Id. at ¶¶ 28-29, 420 P.3d at

  264-65.

¶ 48   In contrast, Rowan’s suggestion that the Johnsons could have

  called Rowan Community following Christal’s admission to request

  a written copy of the agreement assumes that the Johnsons

  recognized the significance of the papers they signed during their

  meeting with Gleisner. This is contrary to the Act’s presumption

  that a patient does not fully appreciate the consequences of signing

  an arbitration agreement while in the stressful process of admission

  to a health care facility. Moreover, the Act specifies that the health

  care provider, and not the patient, bears the burden of complying

  with the Act. See § 13-64-403(12)(a)(I).

¶ 49   In the absence of a meaningful alternative to the requirement

  that the health care provider give the patient a written copy of the

                                      22
  arbitration agreement she signed, Rowan Community could not

  have substantially complied with the Act when it failed to provide

  the Johnson with a written copy of the agreement until after the

  suit was filed.

¶ 50   Therefore, we conclude that the agreement is unenforceable

  because Rowan Community did not substantially comply with the

  “written copy” requirement set forth in section 13-64-403(6).

        2.    Rowan Community’s Failure to Sign the Agreement

¶ 51   Rowan does not dispute that no representative of Rowan

  Community signed the agreement. Rowan initially contends,

  however, that the absence of Rowan Community’s signature does

  not preclude the formation of a contract under common law

  principles. The formation of a contract between the Johnsons and

  Rowan Community under common law principles is not

  determinative, however, because the Act imposes more stringent

  requirements for contract formation than does the common law of

  contracts. Thus, we confine our analysis to the Act’s signature

  requirement.

¶ 52   We agree with the district court’s conclusion that, under the

  Bickel factors, Rowan Community failed to substantially comply

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  with the Act’s signature requirement, in addition to the Act’s

  “written copy” requirement.

¶ 53   Under the first Bickel factor, the court found that Rowan

  Community’s noncompliance with the signature requirement was

  not minimal because Rowan Community directly violated a

  provision of the Act by “fail[ing] to sign and execute the Agreement

  as required by two sections of the [Act].”

¶ 54   The court further found that, under the second Bickel factor,

  Rowan Community’s failure to sign the agreement did not satisfy

  the Act’s purpose. The court explained that the ninety-day

  statutory rescission period, “which is an important safeguard to

  ensure that the statute’s purpose of voluntariness is effectuated,”

  does not begin to run until both parties have signed the arbitration

  agreement.

¶ 55   The language of the Act is unambiguous — the date of the

  “signature by both parties” marks the date on which the ninety-day

  rescission period begins to run. § 13-64-403(3)-(4) (emphasis

  omitted). Without the health care provider’s signature, the

  rescission period never commences. Thus, the purpose of the Act

  that the patient have a meaningful opportunity to rescind an

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  arbitration agreement is not satisfied if the health care provider

  does not comply with the signature requirement.

¶ 56   Finally, although the court found no evidence that Rowan

  Community intended to mislead the Johnsons or acted in bad faith

  by failing to sign the agreement, it could not find that Rowan

  Community made a good faith effort to comply with the signature

  requirement.

¶ 57   We adopt the district court’s thoughtful application of the

  Bickel factors to the signature requirement.

¶ 58   On appeal, Rowan challenges the district court’s holding that

  the Act requires both the provider and the patient to sign health

  care arbitration agreements by contending that the “subsections’

  reference to ‘both parties’ defines a point in time, rather than a

  requirement . . . .”

¶ 59   While we acknowledge that sections 13-64-403(3) and

  13-64-403(4) do not include mandatory language such as “shall,”

  Rowan’s argument is unpersuasive. If the signatures of “both

  parties” were not a requirement for enforcement of a health care

  arbitration agreement, the language of the Act requiring that the

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  patient receive a written copy of the agreement and granting the

  patient a rescission period would make no sense.

¶ 60   Section 13-64-403(6) provides that “[t]he patient shall be

  provided with a written copy of [the] agreement . . . at the time that

  it is signed by the parties.” § 13-64-403(6). In addition, section

  13-64-403(3) states, in relevant part, that the rescission period

  expires “ninety days after the agreement has been signed and

  executed by both parties.” § 13-64-403(3) (emphasis added). Thus,

  the date on which the rescission period began to run and the date

  on which it expired are inextricably linked to the date on which the

  arbitration agreement was “signed and executed by both parties,”

  which, in this case, never happened. Id. For this reason, like the

  written copy requirement, the signature requirement was material

  to the issue of voluntariness.

¶ 61   As noted above, under the Act, an arbitration agreement

  between a health care provider and a patient can be voluntary only

  if the patient has the right to reflect on the implications of signing

  such an agreement and the right to rescind it if the patient changes

  her mind about arbitration. See § 13-64-403(1). Any uncertainty

  as to the date on which the rescission period begins to run

                                     26
  increases the likelihood that the patient will miss the rescission

  deadline. And in this case, the failure of the facility to sign unfairly

  placed the burden of determining when the rescission period began

  to run, and when it expired, on the Johnsons.

¶ 62   Finally, Rowan contends that the missing signature is

  inconsequential because Rowan Community did not “coerce or

  induce Mr. Johnson’s voluntary signature to the Agreement.”

  Rowan is correct that the district court did not find that Rowan

  Community took actions to coerce Mr. Johnson into signing the

  agreement. But the Act does not state that health care arbitration

  agreements are enforceable in the absence of evidence of coercion,

  even if they do not comply with the Act’s requirements. Rather, it

  assumes that some degree of coercion is inherent in the patient’s

  execution of these types of agreements — which is why the Act

  grants the patient a ninety-day rescission period to think over the

  decision to consent to arbitrate and to confer with counsel about

  the merits of arbitration.

¶ 63   This rescission period was necessary here to ensure the

  voluntariness of the Johnsons’ execution of the agreement, given

  the risk of coercion when a patient makes difficult health care

                                     27
  decisions and the patient’s “lack of information” at the time of

  signing an arbitration agreement. Colo. Permanente, 926 P.2d at

  1227 n.17.

¶ 64   Because Rowan Community did not substantially comply with

  sections 13-64-403(3) and 13-64-403(4), the agreement is

  unenforceable.

                            III.   Conclusion

¶ 65   The order is affirmed.

       JUDGE PAWAR and JUSTICE MARTINEZ concur.

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