We offer 3 convenient ways to place an order for records:

• On-Line
  Fill-out this form and submit it electronically by pressing the "Submit Records Order" button. We will contact you by telephone to confirm your order.
  

• Fax or Mail
  Follow this link to a form that you can print, fill-out, and submit via fax or U.S. mail. We will contact you by telephone to confirm your order.

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           On-Line Records Order Form

When this form is submitted outside of normal business hours, Monday-Friday, 7:30 a.m. to 5:30 p.m (CST), it is processed on the next business day.
Date January February March April May June July August September October November December     1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2001 2002 2003 2004 2005 2006 2007 2008 2009 2010	Requested by Telephone Area        Number            Ext.
Cause Number	Secretary or Paralegal

County     Requesting Attorney
Representing	TBA Number

Court Number	Firm
Style of Case      VS.

RECORDS DESIRED Records Pertaining to     Specific Dates (if applicable)
SSN	Date of Birth	Date of Accident
	Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.     1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.     1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

 

CHECK ITEMS REQUESTED
Any and All		Payroll
Bank Records		Personnel
Bills		School Records
Employment		X-Ray Films
Insurance Policies		X-Ray Reports
Medical Records
Other (please specify)

 

CHECK QUESTION FORM DESIRED
Non-Admissible		Prove-Up Admissible
Affidavit		Attorney Furnished

 

OPPOSING COUNSEL
Opposing Counsel - 1		Opposing Counsel - 2
Representing		Representing
Opposing Counsel - 3		Opposing Counsel - 4
Representing		Representing
List any additional attorneys

OBTAIN RECORDS FROM Please furnish any helpful information such as address, telephone, account, authorization of release or patient number, date of service, etc.
1.		2.
3.		4.
List any additional deponents   If no records OBTAIN AFFIDAVIT OF NO RECORDS     Yes     No
Email Address