*For retrieval via subpeona, a WCAB Number/Court Case Number or Application for Adjudication of Claim must accompany request. For Document Retrieval and duplicating via authorization form, an a signed HIPAA compliant authorization must be faxed or mailed to our office:

Terms & Conditions

An alternate printable order form is available here

	DATE ORDERED:	DOCUMENT RETRIEVAL & DUPLICATION VIA: SUBPOENA AUTHORIZATION	STANDARD RUSH	DUE DATE:
	SUBMITTED VIA: PHONE E-MAIL POST OFFICE INTERNET/WEBSITE		DATE RECIEVED:	A&A FILE NO ASSIGNED:

	REQUESTOR NAME:		E-MAIL:
	INSURANCE/COMPANY:	TELEPHONE:	FAX:
	MAILING ADDRESS:
	CLAIM NUMBER:	DATE OF INJURY:	CASE CAPTION:
	WCAB NUMBER:	COURT CASE NUMBER:

	SUBJECT/CLAIMANT NAME:				DEFENSE ATTORNEY:
	AKA:				ADDRESS:
	ADDRESS:				CITY:	STATE:	ZIP:
	CITY:	STATE:	ZIP:		TELEPHONE:	FILE NO:
	TELEPHONE:				APPLICANT ATTORNEY:
	DATE OF BIRTH:	SOCIAL SECURITY NUMBER:			ADDRESS:
	SIGNED AUTHORIZATION FOR RELEASE OF RECORDS ATTACHED: Yes No				CITY:	STATE:	ZIP:
	A&A TO OBTAIN AUTHORIAZATION FOR RELEASE OF RECORDS FROM SUBJECT: Yes No				TELEPHONE:	FILE NO:

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