Sierra Infonet Litigation Support

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Get Records via Workers Comp Subpoena

Ordered By Your Name:
Atty Name: Represents:
Company: Phone:
Street Address: Fax:
City: State: Zip: E-Mail:
Set(s) of records to this address At Our Expense
Bill Another Party

Invoice To Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Pertains To (Applicant) Name:
Soc. Sec: Date of Birth:
DMV No: Other:
AKA:

Claim Info Your Client / Insured*: Date of Loss*:
Other: Claim No*:

Work Instruc-
tions		 Authorization (Copy Faxed to 714-220-0051)
 Rush
Records Deposition (Subpoena Duces Tecum)
 Needed By:
Appear at Hearing / Trial (Subpoena)
 Ordered On:
Search WCAB Claim History
Special Instructions:
Case Name*:
Case #*: (If unassigned attach DWC-1/Adjudication Form)
City*:
Hearing Address: Hearing
Date:  Time: 

Job #1 Name: Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#2
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#3
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#4
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#5
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#6
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#7
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#8
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#9
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#10
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#11
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#12
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#13
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#14
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#15
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#16
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#17
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#18
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  

Job
#19
Name:     Use Attached Job List
Address: Phone:
Fax:
E-mail:
  
Limit Records: From: To:
Medical Records Billing Records All Radiological Films Public Records
Employment Other Records:
  Dup X-Rays CT Scans MRI Films Sign-in Sheets
Attorney Scholastic Insurance  



Other Counsel
Name*: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense
 
Invoice To
Company:
Attention To: Phone:
Address: Fax:
City: State: Zip: E-Mail:

Other Counsel
Name: Represents:
Company: Phone:
Address: Fax:
City: State: Zip: E-Mail:
Use Attached Service List At Our Expense
Set(s) of records to this address At this party's expense
At another party's expense


Attachments

  Example: Job List
  Example: Service List


TERMS AND CONDITIONS

1) Upon express written request, Sierra Infonet Services, Incorporated, (Sierra Infonet), will provide third party direct billing as a courtesy to its customers. However, the firm or company placing the order remains primarily and independently responsible for full payment for all services rendered by Sierra Infonet. An exception will be made when Sierra Infonet has entered into a separate written agreement with an insurance carrier.

2) All invoices are due and payable upon receipt, therefore any invoices that are unpaid beyond 30 days will be subject to a service charge of one and one-half percent (1½%) per month.

3) The parties agree that in the event of a breach of this contract by Sierra Infonet, it would be impractical or extremely difficult to assess the actual damages resulting from such a breach. Therefore, in the event of such breach, Sierra Infonet agrees to pay as liquidated damages and not as a penalty, the sum of $50.00 which sum represents a reasonable endeavor by the parties hereto to estimate a fair compensation for foreseeable losses that might result therefrom. In no event shall Sierra Infonet's total liability or responsibility for any damage resulting from breach of this Agreement exceed the sum of $50.00.

4) This Agreement shall be considered as made in Cypress, Orange County, California for purposes of determining venue for any action on said Agreement. The laws of the State of California shall control this Agreement.

5) In the event of any legal action to enforce this Agreement, or to obtain relief from any breach thereof, the prevailing party shall be entitled to an award of reasonable attorney's fees and costs, in addition to any other relief to which he may be entitled.

6) This agreement may not be modified, cancelled or waived, in whole or in part unless expressly agreed to in writing by all parties hereto.

7) This Agreement constitutes a single integrated written contract expressing the entire Agreement of the parties hereto. There are no agreements, representations, or warranties, written or oral, express of implied, by or between the parties, except as expressly set forth herein.

8) Placement of an order for services constitutes the express agreement of the ordering party to all of the foregoing terms and conditions.