Since the referral obligation must be signed in writing and signed by the parties, many health facilities may find that they need to amend their medical agreements. In particular, at present, the Stark Act does not require that labour relationships be in writing or that they include predetermined compensation. If this change were to be implemented, health institutions will have to define in advance the method of remuneration and implement a written document signed with all employed doctors for whom a specific transfer is required. Recently, at United States ex rel. Emanuele v. Medicor Assocs., 242 F. Supp.3d 409, 431 (W.D. Pa. 2017), new exam denied, No. CV 10-245, 2017 WL 3675921, gave the U.S. .