| Ordering Firm | Billing Firm |
Firm Name Attorney Address City, State, Zip Phone File number | Firm Name Attention Address City,State,Zip Phone Claim number
|
| Ship To |
Firm Name Attention Address City, State, Zip Phone
| Firm Name Attention Address City,State,Zip Phone
|
| Send Notices To (Consumer's notice- CCP1985.3 & 1985.6) |
Firm Name Attention Address City, State, Zip Phone
| Firm Name Attention Address City,State,Zip Phone
|
| Case Information |
Plaintiff | vs. Defendant |
Case Number Country/District | |
| Records Pertaining To |
Name AKA Date of Birth | Medical Records # DOI SSN |
| Records From (Check appropriate boxes) |
M = Medical Records B = Billing Records X = X-Rays E = Employment A = Academic P = Payroll I = Insurance For special instructions, use "Special Instructions" box below. |
| |
Special Instructions |
| Authorization |
I authorize Legal Beagle as our agent in this matter. (type your name to sign) Date |
|