Medical Record Request Submission – Total Trial Solutions

Requesting Firm

Requesting Firm Case #

Name of Requester

Email Address of Requester?

Client First Name

Client Last Name

Client DOB

Client Gender?

Date of Accident

Client Deceased?

Client Last 4 of SSN

Client Street Address

Client City

Client State

Client Zip

Client Phone

Where are the records located (Hospital or Doctor Office Name)?

Date of Service

Please describe the records you are seeking

Please upload your HIPAA or other authorization form here.