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RECORDS REQUEST

* = required fields
 
Requesting Attorney*
Firm Name*
On Behalf Of* Defendant Plaintiff Other
Assistant/Paralegal
Address*
City*
State* Zip*
Phone* Fax
Email Address*
NECESSARY INFORMATION
Name on Record/Patient Name*
Date of Birth* Social Security* #
AUTHORIZATIONS
Authorizations* Obtain from opposing counsel To follow by mail
To follow by fax Attached as PDF None required
 You can upload files in the next step.
DELIVERY METHOD
Format * Standard (Paper)
Online respository only (Discount applies)
Additional Copies     Send a copy of all records to Adjuster Other Counsel
Misc/Special Instructions
CASE INFORMATION
Case Caption
vs.
Court
Case Number Judge
Date of Incident
Opposing Counsel Name
Email Address
Address
City
State Zip
Phone Fax
Please provide Opposing Counsel with Copy (paper records only)
 
Additional Counsel You can attach a list of Counsel (optional) on the next screen.
BILLING INFORMATION
Bill To*: Above Third Party
   
Claim # or Case Billing Ref. #*

PROVIDER INFORMATION
Total No. of Providers
   
Provider 1
Address
Address 2
City
State Zip
Phone
Fax
Records Requested/Duces Tecum
  If yours is not listed, please enter it in the box below.
Please Include
  Specify Body Part and/or Range of Dates
None  
Billing
XRay
CTScan
MRI
Please Include
 
Rush
Notarize
 

 
          
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