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NAME:_________________________________ STATE
FIRM NAME:_____________________________ORDERED BY:____________________
ADDRESS:________________________________________________________________
PHONE:_________________________________ FAX:___________________________
BILLING TO BE SENT TO:_____________________________________________________
REPRESENTS:
[ ] Plaintiff [ ] Defendant [ ] Petitioner
[ ] Respondent [ ] Other
DATE ORDERED:_________________
DATE NEEDED:_____________________
TRIAL DATE:____________________
_________________________________ * _________________________________
_________________________________ * _________________________________
_________________________________ * _________________________________
RECORDS ON INSTRUCTIONS
| FIRST: | [ ] SUBPOENA [ ] Admissible [ ] IN-Admiss. |
| MIDDLE: | [ ] AUTHORIZATION: By Affidavit only |
| LAST: | [ ] OPEN RECORDS: [ ] Plain [ ] Certified |
| DOB: | TYPE OF RECORDS |
| S.S.N.: | [ ] MEDICAL [ ] PHARM [ ] RADIOLOGY |
| DATE OF ACCIDENT: | [ ] PERSONNEL [ ] PAYROLL [ ] INSURANCE |
| CLIENT FILE NO.: | [ ] BILLING: [ ] Standard [ ] Reasonable/Necessary |
| DATES NEEDED: | Other: |
NAME _____________________________ NAME _____________________________
FIRM______________________________ FIRM_______________________________
ADDRESS__________________________ ADDRESS___________________________
CITY/STATE/ZIP ___________________ CITY/STATE/ZIP
______________________
TELEPHONE _______________________ TELEPHONE________________________
FAX ______________________________
FAX_______________________________
REPRESENTS_______________________ REPRESENTS
_______________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
RECORD LOCATIONS
NAME
ADDRESS
PHONE
1.]_________________________________________________________________________
2.]_________________________________________________________________________
3.]_________________________________________________________________________
4.]_________________________________________________________________________
5.]_________________________________________________________________________
6.]_________________________________________________________________________
Please Attach Any Additional Information.