Electronic Order Form

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Electronic Order Form

Type of Request *Deposition Subpoena For RecordsWorkers Comp Subpoena For RecordsSigned Authorization For Records

Attach Autho or other documents

Drag and Drop (or) Choose Files

Date Ordered

Due Date

Discovery Cut-off Date

Rush (Additional charges will apply)

Ordering Party

Company Name *

Attorney/ Adjuster *

Contact *

Email Address *

Phone *

Address *

City *

State *

ZIP / Postal Code *

File/ Claim Number

Billing Information

Ordering Party ViaC.O.D.Use existing card on file or Print, Fill out & Fax or Email New Client ApplicationThird Party

New Client Application

Company Name

Adjuster

Address

City

State

ZIP / Postal Code

Phone

File/ Claim Number

Insured

Date of Loss

Records Pertaining to

Name *

AKA

Date of Birth

Last Four Digits of SS No.0 / 4

Case Information

Plaintiff

Defendant

Court

County

Judicial District

Court Case Number

Representing

Opposing Counsel

Company Name

Attorney

Street Address

City

State/Province

ZIP

Phone

Representing

Name

Service List Attached

Drag and Drop (or) Choose Files

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 CopiesSoft Copies (Available Online)CD’s (Additional Charge)Paginate (Number) Documents (Additional Charge)

Additional support documents not attached to this order can also be faxed to (909) 598-2308 or emailed to orderentry@ronsin.com

To retain a copy, please print before submitting.

Please do not fill in this field.