Cox v. Gritman Medical Center - Personal Jurisdiction Ruling

FOR PUBLICAT ION UNITE D STATES COURT OF APPE ALS FOR THE NI NTH CIR CUIT MARK COX; ESTATE OF SUSAN A COX, by and through Personal Represen tative M ark C ox; SUSAN A. COX, Plaintiffs - Appellants, v. GRITMAN MEDICAL CENTER; PATRICIA N. MAR CIANO, MD; TODD BLEDSOE, PA - C, Defendants - Appell ees, and UNKNOWN PART IES, named “ Others T BD ”, Defendant. No. 24-1947 D.C. No. 2:23- cv -00031- MKD OPINION Appeal from the United States D istrict Court for the Eastern District o f Washington Mary K. Dimke, Distric t Judge, Presiding

2 C OX V. G RITMAN M E DICAL C ENTER Argued and Submitted April 3, 2025 Portland, Oregon Filed February 11, 2026 Before: Jay S. B ybee and Danielle J. Forrest, Circuit Judges, and Xavier Rodriguez, District Judge. * Opinion by Judge Forr est SUMMARY ** Persona l Juri sdicti on The panel reversed the di stri ct court’s dism issal f or lack of personal jurisdiction of a wrongf ul - death and survivor action brought by the Estate of Susan Cox and Susan’s husband Mark Cox (Plaintiffs) against Gritman Medical Center an d Pat ricia M arci ano, Su san’s p rimary care d octo r (Defend ants). Susan and Mark Cox lived in Albion, Washington. Susan died from a n overdose allegedly related to Dr. Marciano’s over - prescripti on of ph armaceut ical drugs. Plaintiffs f iled this action in the Eastern District of Washington. Defend ants are Idaho resid ents, and the * The Hon orable Xavie r Rodri guez, Unit ed Stat es Dist rict J udge for the West ern Dist rict of Texa s, sit ting by designa tion. ** This s ummary consti tutes no part of t he opinion of t he court. It has been pre pared by c ourt staff for the convenie nce of t he reader.

C OX V. G RITMAN M E DICAL C ENTER 3 medical treatments they provided to Susan occurred in Idaho. The pan el held that the d istri ct cou rt’s exercis e of personal jurisdiction over Defendants satisfied Washington’s long - arm s tatut e and th e Due P roce ss C lause of the Fou rteent h Am endm ent becaus e Defen dant s were located on the I daho/ Washington border, specif ica lly cultivate d treatment rela tionships with Wa shington residents, and routinely transmitted Susan’s prescripti ons to Washington pharmacies at her request. The panel did not reach the issue of whe ther the district court properly denied jurisdictional discovery re lated to whether Gritman is subje ct to gener al personal jur isdiction in Washington. Defen dant s are subj ect to sp ecific pers onal jurisdiction in Wash ington, and ther efore Plaintiffs were not prejudiced by the denial of jurisdictional discovery as to general jurisdiction. The panel also held that venue was proper in the Eastern District of Washington because the record establishes that a substantial p art of the events givin g rise to Plaintiff s’ claims occurred in the Eastern District of Washington.

4 C OX V. G RITMAN M E DICAL C ENTER COUNSEL Mary E. Schultz (argued), Mary Schultz Law PS, Spangle, Washington, for Plaintiffs-Appellants. Anne Schroeder (argued) and William J. Schroeder, KSB Litigation PS, Spokane, Washington; Amanda K. Thorsvig (argued) and Michele Atkins, Fain Anderson Va nDerhoef Rosendahl O'Halloran Spillane PLLC, Seattle, Washington; Markus W. Louvier and Sean M. King, Evans Craven & Lackie PS, Spokane, Washington; for Defendants - Appell ees. OPINION FORREST, Circuit Judge: This i s a pers onal - jurisdiction case. Susan Cox allegedl y died of a fatal overdose of medications prescribed by her primary care doct or, Def endant P atricia M arciano. Susan’s husband, Mark Cox, and her estate (Plaintiff s) sued Dr. Marciano an d Gri tman Med ical Cen ter (Defend ants) in the Eastern District of Washington, where the C ox es l ived. The Defend ants ar e Idaho res idents, and the medical treatment they provided to Susan occurred in Idaho. Th e dis trict cou rt denied jurisdictional discovery related to Grit man and dismissed this action for lack of per sonal jurisdiction over Defend ants. Plaintiffs appeal both decisions. I f personal jurisdiction e xists, t he parties als o disp ute whet her venue properly lies in Idaho. We reve rse and reman d. Given that Defenda nts are located on the Idaho/Washington border, that they specifica lly cultivated

C OX V. G RITMAN M E DICAL C ENTER 5 treatment relationships with Washington residents, and t hat they routinely tra nsmitted Susan’s prescriptions to Washing ton ph armacies at her reques t, t he district co urt’s exercis e of perso nal jurisdiction over Defendant s satisfies Washington’s long - arm statute and the Due P roce ss Cl ause of the Fourteenth Amendment. For that reason, we do not reach wh ether the dist rict court prop erly denied jurisdictional discovery. We conclude, moreover, that venue was proper in the Ea stern District of Washington. BACKGROUND The relevant events o ccurred in an area of E astern Washington and Northern Idaho where ther e is signi ficant cross - border activity. Gritman owns and operates numerous facilitie s in Moscow, Idaho — a town locat ed immediately adjacent t o the border. Gritman is incorporated under Idaho law and headquartered in Idaho. It previously had a clinic in Pullman, Wa shington, which neighbors Moscow. But for the last 25 yea rs it has o perated only in Idaho. Gritman adverti ses via billboards, newspapers, radio, television, a nd social media th roughout the Lewis and Cla rk Valley region, which enco mpass es parts of both Idaho and Washington, “to make peop le aw are of Gri tman and the s ervic es Gri tman can provide a t its facilities in Idaho.” Gritman also accepts, and adverti ses that it ac cepts, Washington Medicaid. Susan and Mark Cox lived in Albion, W ashington, which is a small town le ss than 20 miles from Moscow. I n 2016, Dr. Marci ano b egan tre at ing Susan for spinal pain. Dr. Marci ano l ives and practices m edicin e exclusively in Idaho. In 2018, Gritman purchased several clinics from the entity that previously e mployed Dr. Marciano, and Dr. Marciano continued to work at these

6 C OX V. G RITMAN M E DICAL C ENTER facilitie s. 1 Dr. Marci ano p rescri bed Sus an a v ariety of pharmac eutical s, in va rying doses and combinations, including the opioids hydrocodone- acetam inophen and oxycodone- acetamin ophen. Susan could r equest refills of her prescriptions wit hout an appointment, either ov er the phone or through Gritman’s electron ic “Patien t Port al.” Gritman ’s policy was to honor a patient s’ ph armacy choic e, “even if the pharma cy i s located outside of Idaho.” At Susan’s request, Gritman sent her prescriptions to pharmacies in Pullman. I n 2022, Susan died from a n overdose allegedly rel ated to Dr. Marciano’s over - prescription of pharmac eut ical drugs. Plaintiffs filed this wrongful- death and survivor action against Defend ants in the East ern District of Washington. Plain tiffs’ cl aims are b ased on Washington law. D efendants moved to dismiss for lack of personal jurisdic tion and, alternatively, to transfer venue to the District of Idaho. The district court denied Plaintiff s’ request fo r jurisdiction al discovery rel ated to whe ther Gritman is subjec t to general personal jurisdiction in Washington and gran ted Defendants’ motion to dismiss. It held that Washington’s long- arm stat ute did not reach De fend ants and that due process did not permit exe rcis ing specific jurisdiction over these part ies b ecause they did not purposefully avail themselves of the forum or purpose fully direct their case - relate d activities to Was hington. Plaintiffs timely a ppea led. 1 Gritman insists that Dr. Marciano i s an inde pendent contrac tor, b ut i t does not argue that Dr. Marcia no’s purport ed contractor status is re levant to the pers onal - jurisdiction analysis. Thus, we do not a ddress thi s issue. See Maldona do v. Moral es, 556 F.3d 1 037, 104 8 n.4 (9t h Cir. 2009) (“Arguments made in passing a nd inadequat ely briefe d are [forfei ted].”).

C OX V. G RITMAN M E DICAL C ENTER 7 DISCUSS ION A. Persona l Jurisdiction We re view the district c ourt’s dismissal f or lack of personal jurisdiction de novo. Boschetto v. Hansing, 539 F.3d 1011, 1015 (9th Cir. 2008). Where the district court grants dismissal without an evidentiary hearing, as here, the plaintiff “need only make a prima facie showing of the jurisdictional facts” based on the pleadings and affidavits. Id. (citation omitte d). We m ust ac cept as tru e all uncontroverted allegations in the complaint an d resolve disputes in the parties’ affidavits in the plaintiff’s favor, but disputed allegations in the complaint not supported by evidence o r aff idavit s need not be ac cepted as tru e. Id. “Personal jurisdiction over an out -of- stat e defend ant i s proper where permitted by a long-arm statute and where the exercise of jurisdiction does not violate federal due pr ocess.” AMA Multimedia, LLC v. Wanat, 970 F.3d 1201, 1207 (9th Cir. 2020). We address each requirement. 1. Washington’s L ong - Arm Statu te Where no appl icable fede ral stat ute authori z es service of process on an out -of- stat e defend ant, as here, federal co urts look to the law of the s tate in which the district c ourt sits. Fed. R. Civ. P. 4(k)(1)(A); Herbal Brands, Inc. v. Photoplaza, Inc., 72 F.4th 1085, 1089 (9th Cir. 2 023). “In interpreting state law, federal courts are bound by the pronouncements of the state’s highest court. If the particular issue has not been decided, f ederal courts must predict how the state’s highest court would resolve it.” Hemmings v. Tidyman’s Inc., 285 F.3d 1174, 1203 (9th Cir. 2002) (citation omitted).

8 C OX V. G RITMAN M E DICAL C ENTER Washington’s long - arm statute authorizes personal jurisdiction over d efenda nts “who in person or th rough an agent” do var ious act s, including, as relevant here, “ transa ct [ing] . . . any b usiness within [Washington ]” or “ commi [t ting ] . . . a tortious act within [W ashington].” Wash. Rev. Code § 4.28.185(1) (a), (b). Be cause we conclude that the t ransact ion -of-business standard laid out in § 4.28.185(1)(a) has been satisfied, we nee d not address whether a tort has be en committed in Washington under § 4.28.185(1)(b). 2 Section 4.28.185 of Washin g ton’s long - arm statute was enacted in 1959. See 195 9 Wash. Sess. Laws 669, 669 –70. The Washington Supreme Court recognized ea rly on that this statute, “ except as ma y be limi ted by it s terms, ” was intended to “assert jurisdiction over nonresident defendants to the exte nt permitted by the [Fourteenth Amendment ] due- process cl ause.” Tyee Cons t r. Co v. Dulien Steel P rods., Inc., 381 P.2d 245, 247 (Wash. 1963) (emphasis added) (citation omitted); see also Deutsch v. W. Coast Mach. Co., 497 P.2d 1311, 1314 (Wash. 1972) (same). Th us, th e Washington Supreme Court initially held that the personal - jurisdiction inquiry was twofold: (1) whether “ the statutory language purport [s] to extend jurisdiction ” and (2) w hether “ im posing 2 Though thi s analysi s may seem count erintuiti ve given t hat thi s disput e arises und er tort law, the Wa shington Supr eme Court has favorably cited the view that th e transaction - of - business stan dard “is not limited to actions in con tract; it applies as well to actions in tor t when supported by a suffic ient showi ng of facts.” Call ahan v. Keys tone Fire works Mf g. Co., 435 P.2d 6 26, 637 (Wash. 196 7) (quoting Longi nes - Wit tnauer Watch Co. v. Barnes & Reinecke, I nc., 209 N.E. 2d 68, 81 (N.Y. 1965)). W e conclude that the transaction - of - busine ss st andard is rea dily met here, and so we do not opine on whet her the commis sion - of -a- tort analysis would supp ort the s ame result.

C OX V. G RITMAN M E DICAL C ENTER 9 jurisdiction [would] violate c onstitutional p rinciples.” Grange Ins. Ass’n v. State, 757 P.2d 933, 935 (Wash. 1988). As an initia l matter, Dr. Marcia no contends that § 4.28.185(1) (a) does not apply because she did not transa ct business in Washington. We disagree. Section 4.28.185(1) (a) imposes a minima l threshol d: “[t]he transaction of any business within [Washington].” (Emphasis add ed.) Mult iple jurisdictions have interpreted similar statutory language to encompass all business transactions other than the most isolated or irre levant. See, e.g., Paterno v. Laser Spine Inst., 23 N.E.3d 988, 992 – 93 (N.Y. 2014); Cannonball Fund, Ltd. v. Dutc hess Cap. Mgmt., LLC, 993 N.E.2d 350, 369 (Mass. App. Ct. 2013). In other words, the transaction -of- business provision is triggered by all transactions but the kind of “‘random,’ ‘fortuitous,’ or ‘attenuated’” ones that would independently raise due - p rocess concern s. Burger King Corp. v. Rudzew icz, 471 U.S. 462, 475 (1985) (citation omitte d); see also Antonin Scalia & Bryan A. Garner, Reading Law: The Interpretation of Legal Tex ts 247 (2012) (“A statute should be interpreted in a way that avoids placing its constitutionality in doubt.”). We predi ct th e W ashington Supreme Court would adopt this sa me interpr etation. S ee Orkin v. Taylor, 487 F.3d 734, 741 (9th Cir. 2007) (explaining that, in applying state law, this court “must predict how the state’s highest cour t would decide the question”). Becau se th is case rel ates t o Dr. Marciano’s repeated transmission of prescriptions to Washington pharmacies, as discussed further below, the long - arm statute

10 C OX V. G RITMAN M E DICAL C ENTER does not constitute an independent bar to the district court’s exercise of personal jurisdiction. 3 We further note that th e distinction between the statutory analysis under Washington’s long - arm statu te and th e due- process inquiry has eroded over the years. A little over a decade ag o, th e W ashington S upreme Court observed t hat, as relates to the long- arm statute’s transaction - of -business provision, “Washingt on court s are autho rized t o assert personal jurisdiction over nonresident de fendants t o the extent permitted by the feder al due process clause.” Failla v. FixtureOne Corp., 336 P.3d 1112, 1116 (Wash. 2014) (en banc). We are not aware that the Washington Supreme Court has deviated from this pronounce ment in the year s since. Therefo re, whether personal jurisdiction is authorized under the transaction - of- business provision rises or f alls with the due- process analysis. See, e.g., Yamashita v. LG Chem., Ltd., 48 F.4th 993, 996–97 (9th Cir. 2022) (obse rving that, where a state’s long - arm statut e is coext ensive w ith federal due - process req uir ements, “the an swer t o the fe deral law questi on may d ictate t he ans wer to th e state l aw q uestio n”). 2. Due Proces s Because w e conclu de that th e transacti on - of - business provision in Washington’s long- arm statute poses no independent bar to personal jurisdiction, we now consider whether exercising jurisdiction over Defendants comports with due process. The Du e Proces s Clau se of the F ourteen th Amendment im poses three requirements for exercis ing specific jurisdiction over an out -of- state def enda nt: (1) t he 3 Gritman di d not discus s Washingt on’s lon g - arm st atute ot her tha n to note tha t it is coextensive with du e process. Thus, as relates to Gritman, we addres s only the due - process a naly sis. See Maldonado, 556 F. 3d at 1048 n.4.

C OX V. G RITMAN M E DICAL C ENTER 11 defendant must have minimum contacts with the f orum; (2) the claim must “aris e [] out of or re late [] to the defendant’s forum - related a ctivities”; an d (3) “th e exercis e of jurisdiction must comport with fair play and substantial justice, i.e. it must be r easonable.” Briskin v. Shopi fy, 135 F.4th 739, 750 – 51 (9th Cir. 2025) (en banc) (c itation omitted); see Walden v. Fiore, 571 U.S. 277, 28 3 (2014). The plaintiff bears the burden on the first two elements; if they are sati sfied, the defendant bears the burden to show that the final element is not satisfied. Briskin, 135 F.4th at 751. a. Minim um Con tacts A defendant has m inimum c ontacts with th e foru m when that defendant has either purposefully availed itself of the privilege of conducting business in the forum or purposef ully directed its activ ities at the forum. See Hanson v. Denckl a, 357 U.S. 235, 253 (1958); Briskin, 13 5 F. 4th at 750–51. We typically use the “purposeful availment” framing for tort c laims like those as serted i n this case. Herbal Brands, 72 F.4th at 1090. “Purposeful availment ” occurs wh en “the d efend ant has taken del iber ate acti on wit hin th e forum st ate or h as creat ed continuing obligations to forum re sidents.” Impossible Foods Inc. v. Impossible X LLC, 80 F.4th 1079, 1088 (9th Cir. 2023) (citatio n modified); ac cord Burger King, 471 U.S. at 475–76. At bottom, we must “ ask whe ther defendants have volu ntarily derived some b enefit from their inte rstate activities such that they will not be ha led into a jurisdiction solely as a result of random, fortuitous, or attenuated contacts. ” Herbal Brands, 72 F.4th at 1090 (c itation modified); see also Walden, 571 U.S. at 284 –85 (emphasizing that “minimum c ontacts” r equires that the

12 C OX V. G RITMAN M E DICAL C ENTER defendant create contacts with the forum and that th e analysis should be on the contacts with the state, not “with persons who reside there”). Whil e “phy sical p rese nce in th e forum is not a prerequisite to jurisdiction, physical entry into the State — e ither by the defendant in person or through an agent, goods, mail, or some other means — is cer tainly a relevant contact. ” Wa lden, 571 U.S. at 285 (citation omitted). M ere forese eabi lity t hat an act ion wil l cause an injury in the forum is ins ufficie nt to find minimum c ontacts. Burger King, 471 U.S. at 474. We have ex amin ed the due - process requirements for personal jurisdiction in two medical - malp racti ce cas es. First, in Wright v. Y ackley, we held that a South Dakota doctor who prescribed medication to a patient who l ater moved to Idaho was not subject to personal jurisdiction in Idaho. 459 F.2d 287, 289 – 91 (9th Cir. 1972). T he patie nt ha d lived in South Dakota and “was taking drugs acquired by prescr iptions permitting u nlimited refills.” Id. at 288. After moving to Idaho, the patien t sought to refill h er prescriptions at an Id aho pharm acy, and, a t the p atien t’s request, the doctor “f urnished copies of the original prescriptions” to the pharmacy. Id. The p atient sued the doctor in Idaho after suffer ing injuries alle gedly caused by the medication. Id. We held that the S outh Dakota doctor did not purposefully avail himself of the privilege of doing business in Idaho because his only contact with I daho was a “chanc e occurren ce ” resulting from the pa tient’s unilate ral choice to relocate. Id. at 290. T he doctor m ade “no syst ematic o r continuing effort. . . to provide services which [were] t o be felt in [Ida ho].” Id. That effects from the prescription filled in Idaho for eseeabl y would be felt in Ida ho was ins ufficien t to satisfy due process. Se e id. at 289 –90, 289 n.4. Inde ed, w e emphasi zed that for “per sonal s ervices [the] focus must be

C OX V. G RITMAN M E DICAL C ENTER 13 on the p lace where th e services ar e rende red,” o therwis e “rendition of such services” would become “ a portable tort” with personal jurisdiction lyi ng anywher e a pati ent “may choose to go.” Id. at 289–90. On the other hand, in Cubbage v. Merchant we held t hat a n Arizona hospital and Arizona doctors were subj ect to personal jurisdiction in California w here they m ade “continuing efforts to provide services in California, and ha[d] not shown any eff orts. . . to discourage California patients.” 744 F.2d 665, 669 (9th C ir. 1984). In that case, similar to this on e, the hospital and doctors were located in a rural area n ear the A rizona- California border and were licens ed only in Arizona. Id. at 667. Ov er one- fourth of the hospital’s p atients wer e California residents, the hospital and doctors advertised in telephone listings distributed in California, and the doctors parti cipated in Calif ornia’s Medicar e program and received reimbursement from California for service s rendered to its residents. Id. On those facts, w e “dec line[d] to apply Wright ’s broad language,” and inst ead concluded that the defendants’ business and marketin g activities were suffi cient t o satisfy the purposeful- availm ent stan dard. S ee id. at 668–70. Applying these principles to the facts of this case, we conclude that both D r. Marciano and Gritm an hav e purposefully availed themselves of the privilege of conducting activities in Washington such that Plaintiffs have shown suff icient minimu m contacts to sa tisfy the first due- process r equir ement. i. Dr. Marci ano Dr. Marciano’s contacts with Washington are undoubtedly more significant than the South Dakota doctor’s contacts with I daho in Wright. Dr. Marci ano knew

14 C OX V. G RITMAN M E DICAL C ENTER that Susan was a Washington resident during their extended treatme nt relationship. Although the record is silent regarding wheth er Dr. Marciano had other Washington patients, her six - year relationship with Susan is si gnificant. See Burger King, 471 U.S. at 482 (noting that a “20 - year interdependent relationship” with actors in the forum supported personal jurisdiction). But we must look at Dr. Marciano’s “contacts with the forum . . . itself, not [her] contacts with persons who reside there.” Wald en, 571 U. S. at 285. Here, Dr. Ma rciano’s relationship with Susan was “intertw ined with” he r relev ant contacts with Washington. Id. at 286. At Susan’s request, Dr. Marciano se nt Susan’s prescriptions to Washington pharmacies. This act is regulated under Washington law, with which Dr. Marciano complied. Specificall y, state law re quires prescriptio ns sent to Washington to be directed to the patient’s pharmac y of choice. See Wash. Rev. Code § 69.50.312(1). Washington also imposes state - specif ic r equi remen ts governin g both the form of pr escription and refill order s and electronic - prescription system s. See, e.g., Wash. Rev. Code § 69.50.312(1), (6). A p rescribe r who transmits elect ronic prescriptions in Washington without complying with t h at state’s requireme nts is subject to civil penalties. Id. § 69.50.312 (5). Thus, it is fair to conclude that b y agr eeing to send Susan’s prescriptions to Washington, Dr. Marciano sought the privil ege of conducting business in that state, which was a benefi t that could come only from com plian ce with Washington law. See Hanson, 357 U.S. at 253 (“[I]t is essenti al in each case th at t here be som e act by which the defendant purposefully avails itself of the p rivilege of conducting activities within the forum State, thus invoking the benefits a nd protections of its law s.”); Burger King, 471

C OX V. G RITMAN M E DICAL C ENTER 15 U.S. at 476 (explaining t hat wher e a def endant t akes act ion to “engage [] in significant activities w ithin a State,. . . [it] manifes t ly has availed [it]self of the privilege of conducting business [in the forum ], and becaus e [its] act ivit ies are shielded by ‘ the benefits and protections’ of the f orum’s laws it is presumptively not unreasonable to require [it] to submit to the burdens of litigation in that forum as well”). Dr. Marci ano contends that he r contacts w ith Washington were random, fortuitous, and isolated be cause she “directed the prescriptions to Sus an, not Washington.” This argu ment ignores the realities o f th e case. Whi le we have focused on wher e the m edical serv ices ar e provid ed, rather than wh ere t he eff ects o f such treat ment w er e experien ced, to avoid subjecting medical professionals to liability for “portable tort [s]. . . deemed to h ave be en commi tted wher ever th e consequen ces for esee ably were felt,” we h ave als o noted that “the due p rocess test must be a flexible one that will consider the various circums tances of a particu lar c ase.” Wright, 459 F.2d at 290 & n.7. And ou r reasoning in Wright that the “nat ure o f the av erag e doctor’ s locali zed pract ice ” gener ally does not result in a “syste matic or continuing effort on the part of the doctor to provide service s which are to b e felt [outsid e the juris diction in which the doctor is located] ” does not apply here. Id. at 290. Dr. Marci ano pr acticed medici ne in an Id a ho town immediately adjacent to the Idaho/Washington border. S he worked for a medical practice th at contracted to provide physician services to Gritman clinic s. Gritman ’s business model includes serving patients throughout a rural region e ncompassing an area that spans I daho and Washington. And Dr. Marciano had been treating Susan since 2016 and always knew that she was a Washington resident.

16 C OX V. G RITMAN M E DICAL C ENTER Dr. Marciano did not have “substantial or continuous and systematic contacts with [Washington]” such that she is subject to general jurisdiction. Cubbage, 744 F.2d a t 667 (citation modified). But on the record presented, it would be inaccur ate to conclu de th at the nat ure of her p racti ce is localized only in Idaho for purposes of assessing wheth er the exercise of jurisdiction over her in Washington “offend[s] traditional notions of fair play and substantial justice,” Interna tional Shoe Co. v. Washington, 326 U.S. 310, 316 (1945) (citation omitted), becau se she kno wingly and intentionally “ create d continuing obligations to [Washington] resident s, ” Impossible Foods, 80 F.4th at 1088 (citation omitted). She did not transmit merely a s ing le prescription to a st ate th at she could not anticipate her pa tient being in, as in Wright, or provide a singular or dis crete inst ance of car e, as in Lewis. Rather, similar to Cubbage, she was Susan’s primary care doctor, she engaged in “conti nuing efforts ” to provide prescriptions to Washington pharmacies for Susan’s convenience consistent with W ashington law, she “ha[s] not shown any efforts. . . to discourage [Washington] patients,” and there is no evide nce in t he record that subjecting Dr. Marciano to jurisdiction in Washington will chill Defendants from treating Washington patients. 744 F.2d at 669–70. Dr. Marci ano also sugg ests that her conduct cannot constitute purposeful availment beca use she derived no benefit from sending presc riptions to Washington. We rejected a simi lar argum ent i n Cubbage where the Ari zona defendants a sserted that they did not profi t monetarily from partici pating in Cal ifornia’s M edicare p rogram be cause their particip ati on afforded them protections provided by California law. Id. at 668. Likewise, by compl ying with Washington law in transmitting prescriptions to

C OX V. G RITMAN M E DICAL C ENTER 17 Washington, Dr. Marci ano r eceived th e benefit s of su ch compliance. And i t is r easonable to infer that her willingness to comply with patien t re quests to send pre scriptions t o Washington pharmacies made it more likely tha t she would retain Washington patients, like Susan. I n sum, Dr. Marci ano did have contacts with Washington, which were not “an isolat ed occu rrence ” such that she should not “reasonably anticipate being haled into court there.” World - Wide Volkswagen Corp. v. Woods on, 444 U.S. 286, 297 (1980). ii. Gritman Given our analysis re garding Dr. Marciano, the writing is on the wa ll for Gritman. Like the hospital in Cubbage, Gritman ow ns clinics that oper ate adjacen t t o the Idaho/Washington bord er. Like the hospital in Cubbage, Gritman actively works to serve Washington patients by, among other things, advertising in Washington and participating in Washington’s Medicare program. See 744 F.2d at 668–69. And like the hospital in Cubbage, Gritman does in fact serve Washington patients. See i d. at 670. Therefore, Gritman’s contacts with W ashington ar e at least as sign ificant as the Arizona hospital’s c ontacts with California addr essed in Cubbage. Of addit ional rel evance h ere, Gritman also has ch osen t o avail itself of Washington law by elec tronically transmittin g prescriptions to Washington on requ est. See Wash. Rev. Code § 69.50.312. Gritman a dmitted that it s do ctors must comply with Washington law when transmitting prescriptions to a Washington pharmacy and that it could refuse to transmit prescription s out of state. Relat edly, Plaintiffs a llege that Susan’s husband Mark r epeatedly contacted Defend ants “to ex press hi s concern s” about

18 C OX V. G RITMAN M E DICAL C ENTER Susan’s prescriptions, and D efendants refused to d iscuss the issue “because of Washington’s law regarding h ealth care information protection.” Gritman’ s intentional complia nce with Washington law evidences its i ntent to gain the “benefit s and p rotecti ons ” of that l aw, which supports a finding of purposeful availment. S ee Burger King, 471 U.S. at 4 82. Like Dr. M arcian o, Gritman argues that Gritman ’s acquiesc ence to a p atien t’s choice for wher e pr e scriptions are sent is not purposeful availment of another st ate’s market and laws. That is t rue in cases like Wright where t he out-of- state transmission is a singular or isolated occ urrence. 459 F.2d at 290. But for the rea sons already discussed, we reject this argument whe re the out -of- state transmission is a “systematic or continuing effort.” Id.; see also Herbal Brands, 72 F.4th at 1093. Gritman a lso re iterates that its activities are localized only in Idaho bec ause its operations are only in Ida ho. That argument is foreclosed by Cubbage, in which the medi cal c are occurred solely in Arizona over a short period of time, did not involve a lengthy cross -border relation ship, and still gave ris e to perso nal jurisdiction over the hospital in California. See 744 F.2d at 667, 672. b. Relatedn ess The second due- process requirement is tha t th e suit must “‘arise ou t of o r relat e to t he defend ant’s co ntact s’ with the forum.” Ford Motor Co. v. Mont. Eighth Jud. Dist. Ct., 592 U.S. 351, 359 (quoting Bristol - Myers Squibb Co. v. Super. Ct. of Cal., 582 U.S. 255, 262 (2017)). “The first half o f that standard asks about causation; but the back half. . . contemplates th at some relationsh ips will suppor t jurisdiction without a causal showing.” Id. at 362. At bottom, “there mu st be ‘an affi liat ion bet ween the foru m and th e

C OX V. G RITMAN M E DICAL C ENTER 19 underlying controversy, principally, [an] activity or an occurren ce that takes place in the forum Sta te and is therefor e subj ect to th e State’ s regulat ion. ’ ” Bristol - Myers Squibb, 582 U.S. at 262 (alter ation in origina l) (citation omitted). R elatedn ess is eas il y resolved here. Dr. M arci ano’s contacts with Washington — transmitting prescriptions to Washington pharmacies as part of her years - long treatment relationship with Susan — are at the hea rt of thi s medi cal - malpract ice controversy. Plaintiffs allege that Susan overdosed and died from t he medications that Dr. Marcian o prescribed. M ark Cox contends that Susan was on “9 or 10 prescriptions” when she died, including oxycodone, Zoloft, g abapentin, and d iazepa m, and that despite know ing S us an had been falling, was confus ed, “kept r epeati ng her self,” and “appeared daz ed,” D r. Marcian o in creased Sus an’s prescriptions just t wo weeks before h er deat h. Both Dr. Marciano and Gr itman argue that Plaintiffs’ allegatio ns are based on “alleg edly neglig ent decisions . . . made in Idaho” and therefore do not relate to their contacts with Was hington. Defendan ts ar e inco rrect because a “ strict causal rela tionship ” i s not required to establish that a claim is “ relate [d] to the defendant’s contacts with the forum.” Ford Motor Co., 592 U.S. at 362 (citation modified). Agai n, C ubbage is instructive. We held there th at the plaintiff ’s medica l - malpractice claims were related t o the Arizona h ospital and doctors’ advertising in California and participation in Ca lifornia’s Medicare program b ecause t hose a ctivi ties enab led them “to att ract a substantial number of patients from California.” 744 F.2d at 670.

20 C OX V. G RITMAN M E DICAL C ENTER While th e current record in th is case indicates th at Dr. Marci ano determined w hich prescriptions to issue in Idaho, she f acilitated delivery of the prescriptions, including refills, at Washington pharmac ies loc ated cl oser t o Susan’s home. She also adjusted the timing of refills from what she prescrib ed through electronic transmission to the Washington pharmacies. Th ese contact s with W ashington were conducted in compliance with Washington law and relate to Plaintiffs’ allegations tha t D r. Marciano overpres cribed opioids and ot her pharmaceuticals. Id. And as previously discussed, it is rea son able to infer that this cross - border facilitation a ided Dr. Mar ciano in attractin g and ret aining Washington patients. T here is also no basis for distinguishing Cubbage a s t o Gritman. Gritma n’s rel evant Wash ingto n cont acts wer e clearly intended to attract Washington patients to seek care at its I daho clin ics. Id. It attempts to distin guish Cubbage on the basi s that Susan was Dr. M arciano ’s patient before Gritm an acquired t he clin ic where S usan w as trea ted. B ut it does not cite any authority r equiring that a plaintiff a llege they saw or acted upon a defendant’s advertising t o demons trate that the adver tising relates to the lawsu it. Indeed, relevant authority suggests the opposite. Ford Motor Co. involved two negligence and produc t - liability act ions s t emming from accidents involving Ford cars. See 592 U.S. at 356. The Supreme Court rejected Ford’s argument that the suit did not arise from Ford’s contacts with the forums beca use the cars were not sold or manufactured in those states. See id. at 361 – 67. The Court emphasi zed that a strict causal relat ionshi p between the forum contacts and the suit is not required and that Ford’s contacts — extensive advertising of its vehicles — was sufficient. See id. After observing that Ford’s advertising

C OX V. G RITMAN M E DICAL C ENTER 21 contacts were rel ated to t he suit, in part bec ause they “might turn any resident [of the forum] into a Ford owner,” the Court clar ified that the plaintiffs ha d not establi shed a caus al connection between the forum contacts and the lawsuits but that causatio n w as not requi red. Id. at 367. Gritma n does not grapple with Ford Motor Co. 4 And if a product- lia bility suit r elates to a manuf actur er’s adv ertisi ng cont acts, even whe n the product was purchased elsewhere, we see no reason why Plaintiffs’ claims here would not clear that same hurdle. c. Reason abl eness Having concluded that both Defendants had minimum contac ts with Washington and that Plaintif fs’ cla ims are related t o thos e cont acts, we next turn to whether D efendants have made a “co mpel ling cas e” that t he exercise o f jurisdiction in Washington would be unrea sonable because it would not comport with “fair play and substantial justice.” Burger King, 471 U.S. at 47 7–78 (citation omitted). On this point, we consider the following factors: (1) the extent of the d efendant’s purposeful in ter jection into the forum state’ s affair s; (2) the burden on the defendant of defending in the forum; (3) the extent of c onflict with the sovereignty of the defe ndant’s state; (4) the forum sta te’s interest in adjud icating the dispute; (5) the most e fficient judic ial 4 Gritman a ppears t o sugges t that a defe ndant’s foru m contacts m ust be the bu t- for cause of the allege d harm. While some of our caselaw can be read to s uggest t hat causa tion is re quired to s atis fy the second d ue - process requirement, see, e.g., Mattell, Inc. v. Greiner & Hausser GmbH, 354 F.3d 857, 8 64 (9th C ir. 2003), the Supreme Court made c lear in Ford Motor C o. that “an exclusivel y causal test of connection” i s incorrect. 592 U.S. at 366.

22 C OX V. G RITMAN M E DICAL C ENTER resolution of the controversy; (6) the importanc e of the forum to the pla intiff’s interes t in con veni ent an d effecti ve rel ief; and (7) the exis tence o f an al ternati ve foru m. Freestream Aircraft (Bermuda) Ltd. v. Aero L. Grp., 905 F.3d 597, 607 (9th Cir. 2018); accord Burger King, 471 U.S. at 477. N either De fend ant has m ade a su fficient ly compelling showing. i. Dr. Marci ano As we have explained, Dr. Marciano did purposefully interjec t hers elf into Washington affairs, but only in a limited way. Dr. Marciano does not identify any specifi c bur den she would suffer by having to def end this action in Washington, but she does argue mor e generally that subjecting her to persona l jurisdiction in Washington w ill “erec t[] barrier s to health care” that “c ourts have long sought to avoid.” I n a similar vein, she contends that subjecting her to suit in Washington would render malpractice a “portable tort” and doctors will “b e liabl e an ywhere t hey ev er sent a pres criptio n at a pati ent’s request, or even wh erever t he p atien t chose t o bring a written prescription to fill it and consume the medicat ion.” This is hyperbole; our decision does not reac h nearly as far as Dr. Ma rciano suggests. Wright re mains good law: discrete prescription transactions do not create the necessary minimum contacts where the doctor doe s not engage in the type of “systematic or continuing” cross - border activities a t issue h ere. See 459 F.2d at 290. To reiterate from our prior analysis, the significant facts underlying our dec ision here are that (1) the ci rcums tances o f Dr. M arciano ’s pract ice made it specifically advantageous for her to develop

C OX V. G RITMAN M E DICAL C ENTER 23 treatment relationships with residents of the for um, (2) she knowingly developed a lengthy trea tment relationship with a forum resident, and (3) she repeatedly sent prescriptions for that patie nt to pharmacies locate d in that forum in complianc e with that fo rum’s law. R elying on Wright, Dr. Marciano suggests that Washington lack s any in terest i n this dispu te because its “dominant in terest on behalf of its citiz ens. . . is not that they should be free from injury by out -of- state doctors, but rather th at they s hould be able to secure ad equat e medical services to meet t heir n eeds whe rever t hey m ay go.” 459 F.2d at 291. E ven if this factor tends to favor D r. Marci ano, she has not ma de a compelling showing. T he record sugg ests that the r ealities of the region in southeast Washington and northwest Ida ho encou rage cross -border transaction of services. De fendan ts intentionally located their s ervices in Id ah o, but they did so with the expectation that they would also serve Washington patients. Dr. Marci ano also suggests that subjecting her to personal jurisdiction in Washington for transmitt in g prescriptions to t his jurisdiction would mean patients “unilate rally control persona l jurisdiction over their physicians ” because Washington law requires doctors “ to fill patients’ prescriptions at their requested loca tions.” Thi s argument misapprehends Washington law. Wa shin gton does not require that out-of- state doctors send prescriptions to the pharmacy of th e pat ient’s choic e; it requires that prescriptions sent to Washington pharmacies be sent to the pharmacy that the patient chooses. See Wash. Rev. Code § 69.50.312(1), (2)(d) (exempting “[p]rescriptions i ssued that are intended for prescription fulfillment and dispensing outside Washington state”). I f Defendants want to avoid personal jurisdiction in Washington for cl aims based o n

24 C OX V. G RITMAN M E DICAL C ENTER prescription activity, like those presented here, there is an easy solutio n: require patients to f ill their pres criptions in Idaho. Washington law does not prohibit this c hoice, and nothing about our decision gives patients unilater al control over where their medical providers may be s ued. Finally, Dr. Marci ano i mplies that subjec ting her to personal jurisdiction in Washington i s un fair becaus e Washington law is less prote ctive of doctors than Idaho law. 5 But exercise of personal jurisdiction is not the same as choice of l aw; regardles s of where this litigation occurs, Idaho’s substantive law may we ll govern the me rits of thi s case. See Burger King, 4 71 U.S. at 477. Washington applies the Res tatement (Secon d) of C onflict of Law s’ “mos t significa nt relationship” test to de termine the appropria te substantive law governing tort claims. Erickson v. Pharmacia LLC, 578 P.3d 306, 316 (Wash. 2025). Application of that test, not the location of the forum, w ill determine the applicable law gover ning th e merits of this case. Dr. Marciano doe s not address the remaining factors, but for the reasons discussed below as to Gritman, none of the relevant factors, either alone or considered in com bination, compellingly show that subjecting her to per sonal jurisdiction in Washington would violate principles of “fair play and substantial justice.” Burge r King, 471 U.S. at 476– 77 (citation omitted). 5 No doubt t his cont ribute d to D efendants’ c hoice t o establish ope rations only on the Ida ho side of t he border des pite int ending to serve patients from both I daho and W ashingt on.

C OX V. G RITMAN M E DICAL C ENTER 25 ii. Gritman Gritman also mak es sev eral arguments for why subjecting it to personal jurisdiction in Washing ton would be unreasonable, only some of which relate to the fairnes s factors referenced above. First, it suggests tha t even though Plaintiffs’ complaint re lies on Washington law, Washington’s medical - malpracti ce st atute applies only to in - state providers. If true, t his does suggest that Washington ’s interest in adjudicating t hi s case is less ened, but it does not itself di ctate th e p ers onal- jurisdiction analy sis, which focuses on “the defendant’s relationship to t he forum.” Bristol -Myers Squibb, 582 U.S. at 262. Gritman also suggests t hat Swank v. Valley Christian School, 398 P.3d 1108 (Wash. 2017), establi shes t hat exercisi ng p ersonal jurisdiction over Gritman in Washington is unfair. This is not compelli ng because Swank analyz ed Washington’s long - arm statute, not whether jurisdiction would comport with fair play and substantial just ice unde r the Due Proces s Clau se. See 398 P.3d at 1121 –23. And even if Swank had addres s ed d ue process, we are not bound by a state co urt’s in terpretat ion of federal l aw. See Congoleum Corp. v. DLW Aktiengesellschaft, 729 F.2d 1240, 1242 (9th Cir. 1984) (“[T]he state court’s interpretation of federal law does not bind our decision, though it may persuade us to reach a si milar result. ”). Turning more spec ifically to the fairness factors, Gritman asse rts that it has not in jected itself into Wa shington and that Washington has no in terest in adjudicating th is dispute. For the reasons previously explained, Gritman has “reached out beyond its home” in I daho by intentionally seeking Washington patients and allowing its medical providers to fill prescr iptions in Washington consistent w ith

26 C OX V. G RITMAN M E DICAL C ENTER Washington law. Ford Mot or Co., 592 U.S. at 359 (citation modified). Furth er, s tates have a sp ecial interest in preventing tort s committ ed within their borders o r that caus e harm to their r esidents. S ee Keeton v. Hustler Magazine, Inc., 465 U.S. 770, 776 (1984). While D r. Marciano is correct that in the m edical - mal practi ce cont ext th ese interes t s must be weighed ag ainst Was hington’s inte rest in its res idents having access t o medical care, the protection interest s till exists. See Wright, 459 F.2d at 291. Gritman fu rther contends that Washington is n ot the most effic ient forum and that Idaho is an adequate alternat ive. The effici ency fact or “depends ‘primarily [on] where t he witn esses and t he eviden ce are likel y to be located. ’” Fre estream Airc raft, 905 F.3d at 609 (alter ation in original) (cita tion omitted). Here, the witn esses and evidence span Washington and Idaho, meaning Washington is one of two forums where resolution may b e effici ent. Gritman cannot even argue that litigating the dispute in Washington would be inconvenient for its legal counsel, as all parti es’ counsel operate out of offices in Washington. Such a flimsy argument fares espec ially poorly i n a system l ike ours, where efficien cy “is no longer weighed heavily given t he modern advances in communication and transportation. ” Id. (citation omitted). In sum, while no factor overwhelmingly favor s P laintiff s and some factors are either neutra l or slight ly favor Defend ant s, tak en to geth er, Defen dant s hav e not made a compelling showing that r equiring them to defend this action in Washington would violate principles of fair play and substantial justice. Accordingly, w e con clude th at the district co urt erred in dismissing thi s case f or lack of

C OX V. G RITMAN M E DICAL C ENTER 27 personal jurisdiction as to both Dr. Marciano and Gri tman. 6 D efendan ts are subje ct to personal jurisdiction under § 4.28.185(1)(a), related to the tra nsaction of business in Washington, because that provision is coextensive with the Due Proces s Clau se an d exercising personal jurisdiction over Defendants in Washington comports with due process in thi s case. See Failla, 336 P.3d at 1116. B. J urisd iction al Dis covery Plaintiffs a lso appeal the distr ict court’s denial of jurisdictional discovery related to whe ther Gritman is subject to general personal jurisdictio n in Washington. “A n appella te court will not interfe re with the trial court’s refus al to grant discovery except upon the clearest showin g that the dismissal re sulted in actual a nd substantial prejudice to the litigant.” Wells Fargo & Co. v. Wells Fargo Exp. Co., 556 F.2d 406, 430 n.24 (9th Cir. 1977). Be cause we conclude that Def endants are s ubj ect to sp ecifi c person al jurisdiction in Washington, Plaintiffs were not prejudiced by the denial of jurisdictional discovery as to general jurisdiction. C. Venue In the alternative to its jurisd ictional c hallenge, Defend ants argu e that dismissal for improper venue is warrant ed. We revi ew de novo a motion to dismiss f or improper venue under Rule 12(b)(3). Myer s v. B ennet t L. Offs., 238 F.3d 1068, 1071 (9th Cir. 2001). Although the district court did not reach this issue, we ex ercise our discretio n to address it in the first in stance as the question at this stage is pure ly legal. See Planned Parenthood of Greater 6 Plaintiffs conceded at oral argum ent that another De fendan t, T odd Bleds oe, was prope rly dismis sed from this case. Ac cordingly, we affir m the district c ourt’s d ismissal as to Bledsoe o nly.

28 C OX V. G RITMAN M E DICAL C ENTER Wash. & N. Idaho v. U.S. Dep’t of Health & Hum. Servs., 946 F.3d 1100, 1110–11 (9th Cir. 2020). Venue is proper in “a judicial distr ict in which a substantial part of the events or omissions giving rise to the claim occurred.” 28 U.S.C. § 1391(b)(2). The “locus of the injury” is sufficient to establish proper venue. Myer s, 238 F.3d at 1076; see al so 14D Charles Alan Wright & Arthur R. Miller, Federal Practice and Procedure § 3806 (4th ed. 2024) (“In tort cases, courts tend to fo cus on where the allegedly tortious actions took place and where the [noneconomic] harms were felt.”). Bec ause Plaintiffs a llege that Susan ingested her prescr iptions, overdosed, and died near her h ome i n Albion, Washington, th e record establish es that a substantial part of the events giving rise to Plaintiffs’ claim s occurred in the Eastern District of Washington and that venue therein is proper. AFFIRMED IN PART, REVERS ED IN PART, and REMANDED fo r further proceedings. 7 7 Defendants shall bear the costs on appeal. See F ed. R. App. P. 39(a)(4).