Records Imaging Service

Request Records Form

Provider Information

Provider:
Address:
City, State, Zip
Phone:
Records Wanted:
- Any and All Records
- Any and All Bills
- Any and All X-Rays
- Any and All Employment
- Other:
Date Needed By: (MM/DD/YYYY)
Specific Items:
Comments:
Records Must Be Certified: Yes No

Name on Record Info

Name on Record:
Address:
City, State, Zip
Date of Birth: (MM/DD/YYYY)
SSN:
Date of Accident: (MM/DD/YYYY)

Case Information

Name of Court:
Case Name:
Case Number

Requesting Attorney Information

Completion of this section will serve as authorization to sign Subpoena/Notice and Serve Subpoena

Attorney:
Attorney Type:
Firm:
Address:
City, State, Zip
Phone:
File Number:
Claim Number:
Media Type:
Number of Sets:
Comments or Special Instructions

Requesting Firm

Authorization to Request Records, Serve Subpoena and Sign Notice

Firm:*
Phone:*
Your First Name:*
Your Last Name:*
Email Address for Confirmation:*
ASAP / Expedited: Yes No

Additional Attorneys

Attorney:
Attorney Type:
Firm:
Address
City, State, Zip
Phone:
Send Courtesy Copy?: Yes No

Bill To

Same as Requesting Attorney Information:
Company:
Name:
Address:
City, State, Zip
Phone:

Send To

Same as Requesting Attorney Information
Company:
Name:
Address:
City, State, Zip
Phone: