Records Of:

AKA:

Social Security #:

DOB:

Court Case #:

Case Caption:

VS:

Date of Injury:

BILLING INFORMATION

Ordered By:
 Carrier/TPA/Self-Insured Defense Attorney Applicant/Plaintiff

# of Paper Copies:

# of CD's:

Online Only:

Firm

Adjustor

Email

Phone

Insured

Claim File No:

DEFENSE ATTORNEY

# of Paper Copies:

# of CD's:

Online Only:

Firm

Address

Attorney

Secretary

Email

Phone

APPLICANT'S/PLAINTIFFS ATTORNEY

# of Paper Copies:

# of CD's:

Online Only:

Firm

Address

Attorney

Email

Phone

COPY INSTRUCTIONS

 RUSH REQUIRED
Date Due:

Special Instructions: (ie: delivery, ommissions, etc)

 SUBPOENA
 WCAB Civil
 PERSONAL APPEARANCE
Date:
Time:
Dept/Div:
Location:

 AUTHORIZATION ENCLOSED

OBTAIN RECORDS FROM:

 Medical X-Rays Employment Other
Location / Phone 1:



 Medical X-Rays Employment Other
Location / Phone 2:



 Medical X-Rays Employment Other
Location / Phone 3:



 Medical X-Rays Employment Other
Location / Phone 4:



 Medical X-Rays Employment Other
Location / Phone 5:



 Medical X-Rays Employment Other
Location / Phone 6:



 Medical X-Rays Employment Other
Location / Phone 7:



 Medical X-Rays Employment Other
Location / Phone 8:



 Medical X-Rays Employment Other
Location / Phone 9:



 Medical X-Rays Employment Other
Location / Phone 10:


Need more than 10 records?

If yes, please complete this form up to 10 and contact our office at 888.589.1151 to add add'l records to your order.

Records Summary Requested:
 Yes No