record_request | Courtroom Sciences

Records pertain to:

Date of birth :

Social Security Number:

Signature of Records Custodian Notarized?
Yes
No

REQUESTING ATTORNEY:

Requesting Attorney Name:

State Bar #

Representing:

Firm :

Contact :

Client Matter Number :

Email :

Phone:

Fax :

OPPOSING COUNSEL:

Opposing Counsel Name:

Firm :

Contact:

Representing:

Email :

Phone:

Fax :

CASE CAPTION:

Case Caption:

Case No.:

Judge:

Court :

DEPONENT #1:

Name:

Phone:

Authorization:

Select Authorization Files:

Request Billing:

Request Radiology?

Rush

DEPONENT #2:

Name:

Phone:

Authorization:

Select Authorization Files:

Request Billing:

Request Radiology?

Rush

DEPONENT #3:

Name:

Phone:

Authorization:

Select Authorization Files:

Request Billing:

Request Radiology?

Rush

BILLING INFO:

Whom should we bill?

Insurer Name:

Claim #:

Records Request Form

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