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Priority Status  Same Day Rush  48-Hour Rush  24-Hour Rush  Complete by

Order Classification  Subpoena  Authorization  Document Production  Subpoena Attached  Medium

Client Information Client:  Contact / Phone #:  Client Matter #:  Claim #:

Billing Information Bill To:  Address:  City/State/Zip:  Phone/Contact:

Patient/Subject Information Please obtain records of:  List any aka's:  Date of Birth:    SS#:    DOI:

Court/Case Information Type of Court (Select One):  Court/Jurisdiction:  Case Name (Abv.):

Case #:    Hearing Date:  Dept./Room:    Hearing Time:

Facilities / Records' Location(s) Name 1:  Address:  City/State/Zip:  Phone #:  Name 3:  Address:  City/State/Zip:  Phone #:    Name 2:  Address:  City/State/Zip:  Phone #:  Name 4:  Address:  City/State/Zip:  Phone #:

Records Needed  Medical  Billing  X-Rays  Personnel  Payroll  Scholastic

Records to Copy  All available  Date range    to

Special Instructions / Specific Records Needed

Opposing counsel list Name Address City, State, Zip Phone  Additional opposing counsel information or special instructions on attached page

Additional Information:

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