Order Date
Required by / Depo Date
Rush
CASE INFO
RECORDS OF
Case Type
--- Please Select ---
Work Comp
Social Security
Civil
Family Law
Criminal
Name
Case No
AKA
Court Address
SSN
City,St,Zip
,
,
DOB
Applicant / Plantiff
DOI
Defendant
REQUESTOR
Name
Represents
--- Please Select ---
Applicant
Defendant
Co-Defendant
Claimant
Plaintiff
Other
Attorney
Bar No.
Address
Phone
Fax
City, St, Zip
,
,
Contact
Email
BILLING
Bill To
Phone
Attorney/Adjustor
Fax
Address
Claim No.
City, St, Zip
,
,
Insured
PARTIES
Opposing Counsel
Attorney
Address
Phone
City, St, Zip
,
,
Fax
DELIVERY
Deliver
sets to requestor.
Deliver
sets to other.
(example, treating physician, QME, etc., specifiy below)
Name
Name
Address
Address
City, St, Zip
,
,
City, St, Zip
,
,
Special Delivery Instructions
PLEASE INCLUDE; RECORDS TYPE, RECORDS LOCATION, LOCATION ADDRESS, PHONE &
PERTINENT DATES IF APPLICABLE
SPECIAL INSTRUCTIONS
For Workers’ Compensation please include a case number. Where not available, please attach the Application of Adjudication when subpoenaing an insurance company or employer. An Authorization is required for requests for medical records out of state or without a case number. Thank you.
©
2009 Gemini Duplication
All Rights Reserved
