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.