Release forms must be sent to Mobile Copy Service. You can
the forms, fax them to (800) 972-8436, or add them as an
attachment at the bottom of this order form.
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)
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.
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.
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)
Any supplied subpoena verbage will appear verbatim on the subpoena.