Orders

CLIENT INFORMATION:

Prefix	First Name	Last Name
Phone
Email
Company

Contact Person (usually the secretary or assistant).

BILLING INFORMATION:

Prefix	First Name	Last Name
Company
Phone		Email
Address
State	City	Zip

COPY RECORDS PERTAINING TO:

Number of Copies

Hardcopy

Online

Additional Information

Delivery to:

REQUESTING PARTY

OTHER

BOTH

DELIVERY INFORMATION:
(if it's other than the requesting party)

Person Or Business Name
Location	Address
City	State	Zip

RELEASE INFORMATION:

Records Of (Name)

Aka

Birth Date

Date of Loss/Injury

CASE CAPTION

vs.

Case No

Court/District

Representing

OPPOSING COUNSEL/SELF-REPRESENTED INFORMATION

Opposing Counsel	Address
Contact	City	Phone
State	Zip

Case TypeAuthorization EnclosedCivil SDTW.C.A.B.Public Records

Appearance Date

Claim File

SEND A COPY TO:

If you wish this information to be forwarded to anyone else, please provide their e-mail addresses in the field below.
Multiple entries must be separated by a comma.

OBTAIN RECORDS:

Name of Specialist / Record Location	Department	Actions
No Records.

Add New Record

Name of specialist / Record Location

Department/Section

Address

City

State

Zip

Phone

Additional Information

Medical	Billing	X-rays
Employment	Payroll	Insurance

Other

MicroQuick