Request for Records

Paralegal / Secretary:*		Telephone:*
E-Mail:*
Special Instructions:
Due Date:		Priority:	Regular Rushed
Attorney:
Firm:
Address:
City:		State:	Zip:
File No:	Claim No:        Claim Rep:
Case Caption:
Insured:		Accident Date:
Bill To:
Billing Address:
Special Instructions:
Records Pertain To:
Name of Person:		SSN:	DOB:
X-Ray / CT / MRI Film Required?                Yes   No		Certified Records?  Yes   No
Indicate Type of Injury:
Special Instructions:
Record 1 - Code: Select One Medical Financial Employment Insurance Scholastic Xray Other
Record Location:		Telephone:
Address:
Copy any and all records           -OR-   Copy specific records dated from to
Special Instructions:
Record 2 - Code: Select One Medical Financial Employment Insurance Scholastic Xray Other
Record Location:		Telephone:
Address:
Copy any and all records           -OR-   Copy specific records dated from to
Special Instructions:
Record 3 - Code: Select One Medical Financial Employment Insurance Scholastic Xray Other
Record Location:		Telephone:
Address:
Copy any and all records           -OR-   Copy specific records dated from to
Special Instructions:
Record 4 - Code: Select One Medical Financial Employment Insurance Scholastic Xray Other
Record Location:		Telephone:
Address:
Copy any and all records           -OR-   Copy specific records dated from to

Special Instructions:

Phone: (952) 544-0932 • Fax: (952) 541-9761 • E-mail: info@mcsrecords.com
8023 West 18th Street • PO Box 26098 • St. Louis Park, Minnesota 55426

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