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Requestor Information
Bill to
Acquisition
Attach Files
Parties to Notice
Records Pertain to
Instructions
Sets to the Requestor
Shipping Locations
Record Locations
Notifications

Requestor Information
Requested by
Requested for 
If you are placing this order for someone other than yourself (such as an assistant placing an order for an Attorney or an Adjuster)
Bar number 
If you are or are requesting for an attorney, enter the Attorney's Bar Number here
Company
Address
City, state, zip
  • AK
  • AL
  • AR
  • AZ
  • CA
  • CO
  • CT
  • DE
  • FL
  • GA
  • HI
  • IA
  • ID
  • IL
  • IN
  • KS
  • KY
  • LA
  • MA
  • MD
  • ME
  • MI
  • MN
  • MO
  • MS
  • MT
  • NC
  • ND
  • NE
  • NH
  • NJ
  • NM
  • NV
  • NY
  • OH
  • OK
  • OR
  • PA
  • RI
  • SC
  • SD
  • TN
  • TX
  • UT
  • VA
  • VT
  • WA
  • WI
  • WV
  • WY
Phone
E-mail
Represent
  • Defendant/Insured
  • Plaintiff/Claimant
Type of accident
Client/insured
Your file #/claim #
Bill to

Acquisition
Release forms must be sent to Mobile Copy Service. You can e-mail the forms, fax them to (800) 972-8436, or add them as an attachment at the bottom of this order form.
Date requested
Due date
  • Standard Service
  • Rush
Acquire records via
  • Authorization
  • Application for Adjudication
  • Claim Form
  • Public Records
  • WCAB Subpoena
  • Civil Subpoena
  • Personal Appearance Subpoena
  • Uninsured Motorist Subpoena
  • Federal Subpoena
Attach Files
NameDescription 
Parties to Notice 
You will automatically receive a confirmation letter as will the person you are requesting the records for/placing the order on behalf of. However, if you would like us to notify a third party (such as a defense counsel/plaintiff counsel) and give them the ability to acquire a set of the records, we can do so with this information on the order form filled in. (NOTE: This information is required to generate a subpoena of any kind)
Party to Notice 1
Name
Company
Address
City, state, zip
  • AK
  • AL
  • AR
  • AZ
  • CA
  • CO
  • CT
  • DE
  • FL
  • GA
  • HI
  • IA
  • ID
  • IL
  • IN
  • KS
  • KY
  • LA
  • MA
  • MD
  • ME
  • MI
  • MN
  • MO
  • MS
  • MT
  • NC
  • ND
  • NE
  • NH
  • NJ
  • NM
  • NV
  • NY
  • OH
  • OK
  • OR
  • PA
  • RI
  • SC
  • SD
  • TN
  • TX
  • UT
  • VA
  • VT
  • WA
  • WI
  • WV
  • WY
Phone
E-mail
# of paper sets
# of record CDs
Represent
  • Plaintiff/Claimant
  • Defendant/Insured
Records Pertain To

Name (first, last)
Middle name
Suffix
  • Jr.
  • Sr.
Date of birth
Social security #
Other names/AKA (one per line):
Date of incident
Body parts injured
Instructions
Copy records
  • Any and all records
  • See specific instructions
  • All records prior to date of loss
  • All records from date of loss to present
  • All records from date below to present
  • All records prior to date below
  • All records between the two dates below
Sets to the Requestor
# of paper sets
# of record CDs
Additional Shipping Locations
Here you can specify additional recipients (other than yourself) who will receive sets of records. To specify the number of sets sent to yourself, please use the "Sets to the Requestor" section instead, which is found above this one.
Shipping Location 1
Name
Company
Address
City, state, zip
  • AK
  • AL
  • AR
  • AZ
  • CA
  • CO
  • CT
  • DE
  • FL
  • GA
  • HI
  • IA
  • ID
  • IL
  • IN
  • KS
  • KY
  • LA
  • MA
  • MD
  • ME
  • MI
  • MN
  • MO
  • MS
  • MT
  • NC
  • ND
  • NE
  • NH
  • NJ
  • NM
  • NV
  • NY
  • OH
  • OK
  • OR
  • PA
  • RI
  • SC
  • SD
  • TN
  • TX
  • UT
  • VA
  • VT
  • WA
  • WI
  • WV
  • WY
Phone
# of paper sets
# of record CDs
Record Locations 
These are the location(s) that we will be acquiring the records from. You can enter all custodians on one order, it is not necessary to input individual custodians on individual orders, this can be done by clicking on "Add another record location" at the very bottom of the section.

If you have a list of the providers, you can append that list to the order form by clicking on the "Add attachment" button to eliminate having to complete the "Records Locations" section(s) of the order form.

The Facility File # is not required but can be filled in should you have the custodians file number (such as a Medical Record Number or a Claim Number or a Case Number for the records you are wanting to acquire)
If you have a patient history sheet, you can send it to us as a fax, e-mail attachment, or order attachment and leave this section blank.
Any supplied subpoena verbage will appear verbatim on the subpoena.
Record Location 1
Doctor's name
Facility name
Address
City, state, zip
  • AK
  • AL
  • AR
  • AZ
  • CA
  • CO
  • CT
  • DE
  • FL
  • GA
  • HI
  • IA
  • ID
  • IL
  • IN
  • KS
  • KY
  • LA
  • MA
  • MD
  • ME
  • MI
  • MN
  • MO
  • MS
  • MT
  • NC
  • ND
  • NE
  • NH
  • NJ
  • NM
  • NV
  • NY
  • OH
  • OK
  • OR
  • PA
  • RI
  • SC
  • SD
  • TN
  • TX
  • UT
  • VA
  • VT
  • WA
  • WI
  • WV
  • WY
Phone
Facility file #
Record types
 
Special instructions to Mobile Copy Service
Subpoena verbage or instructions to custodian
Attachments for this location:
NameDescription
Send Notifications
Below, you can supply a list of e-mail addresses which will receive a notification letter when we process your order.

Send a notification to:


E-mail address: