Order

This form represents the information we need to accomplish our mission for you. We realize that information comes in all forms and that the last thing you need in your day is a waste of time. If you have the information that is needed on the ORDER FORM in some other format; (i.e., 1st answer to interrogatories or other requests for production), just cut and paste what you want and e-mail or simply cross off what is not wanted and circle what is wanted and fax, mail or have our courier pick up. Or if you have a social security printout with employers and dates of employment, just mark it up and send it our way, we'll do the rest. We might need to touch base with you to fine tune the language in records requested or pertinent dates, etc. Our sole mission is to make your work life easier and anything we can do to facilitate this will be done.

Order for Medical Records

Your Name:
Your Email: 

Deponent(s) from Whom Records are Sought (including name, address, phone and fax numbers):


Patient's DOB, SSN or other important information:

Standard request for medical records?
Yes  No

If not standard request, please specify records needed:
 
Do you want billing records?
  Yes  No
Admissible  Inadmissible w/ Affidavit

Requesting Parties' Affiliation:
Plaintiff's Counsel   Defendant's Counsel
Other, please specify

 Plaintiff's Counsel's Address & Information:

Defendant(s) Counsel's Address & Information:

Other Party's Counsel's Address & Information:

Style of your case:


Court Information:

Anything else we need to know to get your records, including billing instructions, contact information including email address and/or client billing reference: