Fill and Sign the To Serve Subpoena on Non Party Form

- 1 - IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________ ) ) ) Petitioner/Plaintiff, ) ) ) NO. Vs. ) ) ) Respondent/Defendant ) ) NOTICE OF INTENT TO SERVE SUBPOENA ON NON-PARTY Take notice that upon the expiration of ___________ ( ) days from the date of service of this Notice, Defendant, _________________, Inc. Inc., will apply to the Clerk of this Court for the issuance of the attached subpoena directed to the _________________ Medical Center, who is not a party and whose address is __________________________________, _________________, to produce copies of the following documents: "Any and all medical records, correspondence, notes, memoranda, reports, x-rays or other documents, including an itemized statements of charges, which relate to the treatment and medical condition of _________________, who resides at __________________________________, _________________; Social Security Number _________________, injured on the _____ day of ____________, 20____." - 2 - Respectfully submitted, Dated: Name: Title: Address: Address: City, State, Zip: Phone: Fax: E-Mail: Attorney No.: CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. _________________________________