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.

Multiple Record Request Form

Deponent: Address: City: Phone:

Records Wanted:

Records Wanted:

Name on Record:
Address:
Date of Birth: Date of Accident: SOC. SEC. NO.

Court: Case Number:

Name of Case:

Plaintiff's Attorney:
Address:

Defendant's Attorney:
Address:

Other Attorneys:
Address:

Requesting Firm: Bar Number:
Date of Request: Requested By:
File Number: Claim Number:
Admissible: Inadmissible W/Affidavit: File Certificate: Do Not File a Certificate:

For Office Use Only Needed By: Court Copy: Yes No
Date Request Received: For Direct Billing: Insurance Co.
Date Record Billed: Time:

Because our firm gathers, stores and electronically transmits medical records (Protected Health Information-PHI), we are required to post notice that protected health information is subject to electronic disclosure.

Texas and Federal Law prohibits any electronic disclosure of protected health information to any person without a separate authorization for each disclosure. This authorization for disclosure may be made in written or electronic form or in oral form if it is documented in writing.

The authorization for electronic disclosure of protected health information described above is not required if disclosure is made: to another covered entity, as that term is defined by Section 181.001, or to a covered entity, as that term is defined by Section 602.001, Insurance Code, for the purpose of: treatment; payment; health care operations; performing and insurance or health maintenance organization function described by Section 602.053, Insurance Code; or as otherwise authorized or required by state or federal law. In other words, no further release is necessary for electronic disclosure to other health care providers, insurance companies, governmental agencies, or lawyers representing adverse parties.