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Record Request

INSTRUCTIONS: Please fill out all of the information in the cells next to the highlighted areas. Begin in the section entitled:  YOUR COMPANY INFO. When completed, click on the send button and your request will be submitted to SDT Services.

Use the tab key to move from cell to cell.

Record Request Form

ADDRESS:

POST OFFICE BOX 120

CITY:

SIMI VALLEY, CA  93062

PHONE NUMBER:

(805) 581-0031

FAX / E-MAIL:

(805) 522-3561 / sdt1@sbcglobal.net

YOUR COMPANY INFO

DATE:

REQUESTED BY:

COMPANY NAME:

ADDRESS:

CITY:

PHONE NUMBER:

FAX:

E-MAIL:

CASE INFORMATION

EMPLOYER / DEFENDANT:

CLAIM NUMBER:

WCAB NUMBER/COURT CASE NUMBER:

APPLICANT’S COUNSEL

ADDRESS:

CITY:

DEFENSE COUNSEL / CARRIER INFORMATION:

CLAIMS ADJUSTER NAME:

EMAIL:

ADDRESS:

CITY:

CLAIMANT INFORMATION

CLAIMANT NAME:

AKA NAME (IF ANY):

CLAIMANT ADDRESS:

CLAIMANT PHONE NUMBER:

DATE OF INJURY:

DATE OF BIRTH:

SSN:

SPECIFIC WORK REQUESTED

 PREPARE SUBPOENA
FURNISH ADDITIONAL SET(S)

 AUTHORIZATION TO BE FAXED/EMAILED

 RUSH (extra charge will apply)
NEED BY DATE: 

OBTAIN RECORDS FROM

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

MEDICAL  EMPLOYMENT   LEGAL FILE   X-RAYS OTHER

CLAIMS (Claim#/DOI/INSURED):

NAME:

ADDRESS:

TELEPHONE:

SPECIAL INSTRUCTIONS:

NOTES:
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