Order Records

Your Law Firm Information

Law Firm Name:

Law Firm Address:

Law Firm City:

Law Firm State: ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingSelect the StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Law Firm Zip:

Law Firm Phone:

Attorney Name:

State Bar Number:

Representing:

Contact Information

Your Name:

Your E-mail:

Contact Phone#:

Direct Questions Form

Please choose the form of direct questions required.

AdmissibleInadmissible with AffidavitAuthorization with Affidavit

Case Information

Style of the Case:

Cause No.:

Court:

County of:

Depo/Trial Date:

Attorneys of Record

Please list all attorneys of record in this case.

Attorney 1Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 2Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 3Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 4Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 5Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 6Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 7Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 8Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 9Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Attorney 10Who Represents:

---PlantiffDefendantCounter-PlaintiffCounter-DefendantCo-PlaintiffCo-DefendantPetitionerRespondentIntervenorPro SeThird Party

Your Records Order

Please fill out who you would like to order records of.

First Name:

Middle Name:

Last Name:

Social Security Number:

Date of Birth:

Other Identifying Information:

Type of Records Needed

Please Indicate what type of records you are ordering.

Medical RecordsBilling RecordsBilling Records (Proved Up)Radiological FilmsPersonnel RecordsPayroll RecordsPolice Records

Other Records:

Date of Records

Any and All DatesThe Following Dates Only:
FROM:
TO:

Affidavit of No Records

If no records are available, do you require an Affidavit of No Records?

YesNo

Records Locations

Please list all locations that would have the records you are ordering.

Location 1Location 2

Location 3Location 4

Location 5Location 6

Location 7Location 8

Location 9Location 10

Insurance Billing

Please indicate wheather we are to directly bill an insurance company.

Bill Insurance Company? YesNo

Insurance Company:

Adjuster/Supervisor:

Claim No.:

Billing Instructions:

Comments and Instructions

Comments and/or Special Instructions:

Attach Any Additional Documents

If you would like to send us additional documents for your records order, please upload the files from your computer. Your attachments cannot total to over 5 MB (5 Megabytes). PDF format or DOC format preferred.

Attach Notice:

Attach Notice:

Attach Notice:

Disclaimer

Please note that your records order is not officially placed with us until we contact you for confirmation. By filling out the form above, you understand that the records order is not guaranteed until it is confirmed by our records department, who will contact you at their soonest opportunity.

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