Fill and Sign the Notice to Patientsubpoena Duces Tecum for Form

NOTICE TO I NDI VIDUAL— SUBP OENA DUCES TECUM FO R HEALTH RECORDS Commonweal th of Vi rginia Va. Code § 3 2.1-127.1:03 NOTICE T O INDIVIDUAL: The attached docum ent m eans that ........................................................................\ ...............................................................................................................................\ ............... has either asked the court to issue a subpoe na or a subpoena has been issued by the ot her party’s attorney to your doctor, othe r he alth care p rovide rs, or oth er h ealth care en tity : ........................................................................\ ...............................................................................................................................\ ............... requiring them to produce your health records. Your doctor, other health care p rovid er, or oth er health care entity is required to respo nd by provid ing a copy o f your health records. If you believe your health records should not be disclosed and object to th eir disclosure, you have the right to file a m otion wit h the clerk of the court to quash the subpoena . If you elect to file a Motion to Quash, such motion m ust be filed within fifteen (15) days of the date of the request or of the attorney-issued subpoena. You m ay contact the clerk’s office to determ ine the requ irem ents th at m ust be satisfied when filin g a m otion to quash and you m ay elect to contact an attorney to represent your interest. If you elect to file a m otion to quash, you must notify your doctor, other health care provider(s), or othe r health care entity , that you are filing the m otion so that the health car e provider or health care en tity knows to send the record s to the clerk of court in a sealed envelope or package for safekeep ing while your motion is decided. FORM DC- 348 (PAGE ONE OF ONE) 07/04 PDF