Records Request – eMax Discovery

ORDER DATE:

DUE DATE:

Records Request Form

RUSH SERVICE

ADD TO EXISTING ORDER:

A. REQUESTER

* FIRM NAME: ATTORNEY:

STREET:

CITY: STATE: ZIP:

* PHONE: FAX: * EMAIL:

* CONTACT: AUTHORIZING SIGNATURE:

CLEAR SIGNATURE PRINT NAME:

B. CLAIMANT INFORMATION

NAME:

AKA:

DOB: SSN:

CASE#:

DOI(From): DOI(To):

STREET:

CITY:

STATE: ZIP:

C. INSURANCE / BILLING

CARRIER:

CLAIM#:

STREET:

CITY: STATE: ZIP:

PHONE: FAX:

ADJUSTER: ADJUSTER CONTACT:

DEFENSE ATTORNEY:

REQUEST RECORDS FROM INSURANCE CARRIER

D. EMPLOYER INFORMATION

COMPANY: SUBSIDIARY PARENT CO. DBA:

STREET: CITY:

STATE: ZIP: PHONE: FAX: EMAIL:

REQUEST RECORDS FORM EMPLOYER

E. DELIVERY

FORMAT: PAPER ELECTRONIC COPIES:

DELIVERY ADDRESS SAME AS REQUESTER

STREET:

CITY: STATE: ZIP:

F. NOTES / INSTRUCTION

NOTES / ADDITIONAL INSTRUCTION:

G. LOCATIONS

1 NAME:

RECORD TYPE:

STREET:

CITY: STATE: ZIP:

PHONE: FAX:

DATE RANGE:

2 NAME:

RECORD TYPE:

STREET:

CITY: STATE: ZIP:

PHONE: FAX:

DATE RANGE:

ADD LOCATION +

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Submit records request form by email to orders@emaxdiscovery.com or fax to (714)380-6839