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
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)
1
 
Copy all dates: or
From Date:
To Date:
2
 
Copy all dates: or
From Date:
To Date:
3
 
Copy all dates: or
From Date:
To Date:
4
 
Copy all dates: or
From Date:
To Date:
5
 
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
 
Security code is case sensitive
 
     
     

 










 
 

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