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Dallas Office P.O. Box 28539 Dallas, Texas  75228 972-613-9444 or 888-553-6588 fax: 972-279-6550

TRI-VECTOR CORPORATION Litigation Support Specialists Records Order Form

Tyler Office 122 S. College, #208 Tyler, Texas  75702 903-533-8002 or 800-794-2184 fax: 903-533-8801

 

Style:	___________________________	Attorney:	____________________________
.		.
	___________________________	Firm:	____________________________
		.
	vs.	Address:	____________________________
		.
	___________________________	.	____________________________
		.
	___________________________	Tel:	___________   Fax : _________
.		.
Judicial Dist.:	___________________________	.
.		Attorney:	_____________________________
Cause:	___________________________	.
.		Firm:	_____________________________
Date Ordered:	____________  By:  __________	.
.		Address:	_____________________________
Date Needed:	_______  Trial/Depo Date ________	.
		.	_____________________________
Client File #:	___________________________	.
		Tel:	___________   Fax : _________
Ordering Atty.:	___________________________	.
.		.	(List others on separate page)
		.
State Bar #:	____________________________	.
.		.	Instructions:  Obtain records by:
Firm:	____________________________	[]-	Deposition by written questions: non admissible-
.			plus affidavit
Address:	____________________________	[]-	Deposition by written questions: non admissible-
.			(disqualifying custodian) plus affidavit
	____________________________	[]-	Deposition by written questions:  admissible
.		[]-	Deposition by written questions:  admissible-
Tel:	__________   Fax : _________		(disqualifying custodian)
.		[]-	Authorization
Representing:	[]- Plaintiff            []- Defendant	.
			Type of Record:
		[]-	Medical (from date of accident only)
	DIRECT BILLING INFO:	[]-	Medical (any & all)
Ins. Co.	____________________________	[]-	Billing (from date of accident only)
.		[]-	Billing (any & all)
Claim # /	____________________________	[]-	Personnel
Adjuster	____________________________	[]-	Payroll
Address	____________________________	[]-	Other
.
	____________________________		Workers Comp?  []- Yes           []- No

 
 

OBTAIN RECORDS ON: . _____________________________________________________________________    First Middle Last    DOB: ___________ Social Security Number: ___________ Date of Accident: __________ .  Any other information:  _______________________________________________________

 
 

RECORD LOCATION(S)

ADDRESS

TELEPHONE NO.

DATES

 

.  1) ___________________________________________________________________________

.  2)____________________________________________________________________________

.  3)____________________________________________________________________________

.  4)____________________________________________________________________________

.  5)____________________________________________________________________________

. List others on separate page