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Record Retrieval Order Form

Is this a new case order for DC Medical *

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Is this an Add-On Case Order previously worked on by DC Medical *

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Phone *

General Information

Ordered by

Email *

Date Ordered

Deposition Date

Cause #

Court Type

District#

Trial Date

County Court #

County of

Claim/File no.

Style of Case

Ordering Attorney

Full Name

Email Address

Represents

Address

Bar #

City

State

Postal code

Telephone

Firm

Fax

Billing Information

Name (Billing Information)

Company (Billing information)

Email Address ( Billing Information)

Telephone (Billing Information)

Address (Billing Information)

City (Billing Information)

Date of Loss

Client File No

State (Billing Information)

Zip Code

Claim No

Ordering Attorney

Attorney

Firm (Ordering Attorney)

Address (Ordering Attorney)

Email (Ordering Attorney)

Fax (Ordering Attorney)

Telephone (Ordering Attorney)

Representing (Ordering Attorney)

Record Information

Records Pertaining to

Date of birth

Social Security # (only last 4 digits)

Any Alias

Type of Record Requested

Medical

Billing

Authorization

Payroll

Non-Admissible

X-Rays

Admissible

Employment

Personnel

Other

Date Range of Records requested

Record Information

Custodians

Telephone/Fax Number

Add files

Location (Record Information)

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Record Retrieval Form