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	Record Retrieval
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For non-registered clients

Type of Request

* Required fields

Deposition Subpoena For Records:

Workers Comp Subpoena For Records:

Signed Authorization For Records:

(Send signed authorization via fax to (909) 598-2308 or email to orderentry@ronsin.com)

Date Ordered:

Due Date:

Discovery Cut-off Date:

Rush (Additional charges will apply)

ORDERING PARTY

Company Name*:

Attorney/Adjuster*:

Contact*:

E-mail Address*:

Phone Number*:

Address*:

City*:

State*:

Zip*:

File/Claim Number:

BILLING INFORMATION

Ordering Party Via:

C.O.D. Credit Card

AUTHORIZATION TO CHARGE A CREDIT CARD:

Use Existing card on file or Print, Fill out & Fax New Client Application

Third Party

Company Name:

Adjuster:

Address:

City:

State:

Zip:

Phone:

Claim Number:

Insured:

Date of Loss:

RECORDS ON

Name*:

AKA:

Date of Birth:

SS No.:

CASE INFO (Needed for all subpoena orders)

Plaintiff:

Defendant:

Court:

County:

Judicial District:

Court Case Number:

Representing:

Plaintiff:

Defendant:

OPPOSING COUNSEL (Needed for all subpoena orders)

Company Name:

Attorney:

Address:

City:

State:

Zip:

Phone:

Representing:

Name:

Large service list emailed to orderentry@ronsin.com

Additional Opposing Counsel:

FACILITY INFORMATION:

Enter the facility name, complete address, phone number and what type of records you are requesting in each box.

Use the following codes for record types:
(M) Medical (B) Billing (X) X-Rays (I) Insurance (E) Employment (O) Other (provide a description)

Copy all dates: or

From Date:

To Date:

Copy all dates: or

From Date:

To Date:

Copy all dates: or

From Date:

To Date:

Copy all dates: or

From Date:

To Date:

Copy all dates: or

From Date:

To Date:

Special Instructions And/Or Additional Locations:

	Hard Copies	Soft Copies (Available Online)
	CD's (Additional Charge)	Paginate (Number) Documents (Additional Charge)

		To retain a copy, please print before submitting.
		Check to Confirm Order Request