DATE
Records Custodian for
NAME OF MEDICAL PROVIDER
ADDRESS OF MEDICAL PROVIDER
RE: NAME OF PATIENT
DOB: DD/MM/YYYY
CASE NAME: PLAINTIFF(NAME) v. DEFENDANT(NAME)
Dear Custodian of Records:
Enclosed herein is a Subpoena and Notice of Deposition of Duces Tecum directing your
appearance at a records deposition which is scheduled for (DATE/MONTH/YEAR) at (TIME),
at (LOCATION ADDRESS), in (CASE NAME, United States District Court, Case No.
00000000. Please provide me with copies of any and all records pertaining to medical records for
(PLAINTIFF’S NAME) relating to treatment of (PLAINTIFF’S NAME) for dates of service on
(DATE/MONTH/YEAR).
YOU MAY FORGO YOUR APPEARANCE AT THE DEPOSITION IF THESE
RECORDS ARE FORWARDED TO ME BEFORE THE DATE OF THE DEPOSITION.
Please send the records to (ADDRESS)
Also please sign and attach to the records a standard Certification. I have provided a Certification
of Records Custodian for your convenience.
Should you have any questions, please contact our office.
Thank you for your cooperation.
Sincerely,
_______________________
(ATTORNEY’S NAME)
Bar #
Counsel for Defendant
Attorney’s Address
Enclosures
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