Records Request Form


Issuing Attorney



Opposing Counsel


Billing Information

 

Case Information



Who Do You Need the Records Of?




Provider/Entities

Provider / Entity 1


Provider / Entity 2


Provider / Entity 3


Provider / Entity 4


Additional Providers

Provider / Entity 5


Provider / Entity 6


Provider / Entity 7


Provider / Entity 8


Provider / Entity 9


Provider / Entity 10


Provider / Entity 11


Provider / Entity 12


Provider / Entity 13


Provider / Entity 14

Upload Release and/or Other Documents

PDF or TIF files only:


IMPORTANT: Make SURE that only the last 4 digits of any Social Security Numbers on the releases are shown. Any submitted files with full SSNs will need to be removed by DocuRom and resubmitted.



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Records Request

Subpoena Request

Schedule a Deposition

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