| ORDERED BY: Fill in this section completely. The attorney's full name and bar # is necessary to issue a subpoena. Be sure to indicate who you represent. Include your file number, if any, to help us reference you back to the proper file. RECORDS PERTAIN TO: Fill in this section completely to insure that Sierra InfoNet copies records on the proper person, entity or case. Include identifying information that will assist the custodian's search, such as social security number, and date of birth. INVOICE TO: If "other," be sure to include carrier information including Adjusters Name, Claim File Number, Date of Loss, and Client Insured. The carrier cannot make payment without this information. SHIP TO: If "other," be sure to specify street address. Records cannot be shipped UPS or hand delivered to a P.O. Box. RELEASE: Authorizations require a date & signature and should contain the name of the Custodian of Records and expiration date. C.C.P. 56.10. When issuing a WCAB subpoena please provide the case name along with the WCAB case number and /or a DWC-1 form. Include the name and address of applicant's counsel. When obtaining records by civil subpoena, please specify the type of subpoena; court location, case number and name Exactly as filed with the court. It is important that you list all opposing counsel as well as co-defense and if more than one opposing counsel please specify plaintiff's counsel. When requesting records from any Kaiser facility, the following is needed: if the patient was treated as an outpatient or treated and released from the "ER," the specific words "Southern California Permanent Medical Group" must be stated on the authorization or subpoena. If the patient was admitted and treated as an inpatient the release must specify "Kaiser Hospital". If you do not know and want us to open both the Hospital and Clinic locations, please indicate. RECORDS LOCATION: Provide as much information as possible regarding custodians of records, including names, addresses and telephone numbers. When subpoenaing insurance records and the insured is different than whom the records pertain to, please provide us with the name and address of counsel representing the insured or the insured's last known address in order to mail notice to consumer. If you are requesting ambulance records please provide the approximate time of day, date and the location of the accident. COPY INSTRUCTIONS: Indicate how many sets of records you wish to receive, as well as the specific type of records, i.e., medical, employment, etc. If you would like us to obtain x-rays, billing records, etc., you must check the special boxes provided. Other services such as indexing the chart must also be checked in the appropriate box. Be specific and use the special instructions section of the order form when you need to provide us special information or when you require services not listed on our order form. When requesting specific dates of records to be copied make sure you mark the box copy only these dates and provide us with the date range. Remember that all records will be copied unless otherwise specified. Please date and sign the order form.
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