Michigan > Workers Comp
Subpoena For Production Of Records And Or Witness Subpoena WC-508 - Michigan
| Subpoena For Production Of Records And Or Witness Subpoena Form. This is a Michigan form and can be used in Workers Comp . |
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State of Michigan Department of Licensing and Regulatory Affairs Michigan Administrative Hearing System/ Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 SUBPOENA FOR PRODUCTION OF RECORDS (and/or) WITNESS SUBPOENA Defendant(s) v Plaintiff Last 4 digits of injured worker's social security number: TO: YOU ARE ORDERED: 1. to produce on or before ________________________ the following records, papers, books and documents, or make the materials reasonably available for copying when received: 2. to appear personally before ____________________________ on: Date: Time: Location: 3. to both produce the items designated in Number 1, and to appear personally as outlined in Number 2. If you refuse to obey this subpoena, refuse to be sworn or testify, or fail to produce such material as you have been ordered to produce, you may be found guilty of contempt and punished accordingly in any circuit court within whose jurisdiction the offense is committed and for which purpose the court is given jurisdiction. Note: If copies of business/medical records are mailed, the records custodian shall complete the certificate on the backside of this subpoena and attach a complete copy of the original business/medical records to the subpoena. DO NOT SEND RECORDS TO THE WORKERS' COMPENSATION AGENCY OFFICE All items specified in Number 1 above are to be forwarded to: Name of attorney/party requesting subpoena (please print or type) P Number Representing Telephone Number City State ZIP Code Email Street Address By requesting this subpoena, the attorney/party certifies that the matter about which this subpoena is issued is pending before the Agency and is issued in compliance with MCL 418.853 and Rule 418.56. This subpoena must be signed by an Attorney of Record, Magistrate, Workers' Compensation Agency Director, or Chair of the Michigan Compensation Appellate Commission. Name (please print or type) Plaintiff Attorney Name, P#, Address, Phone P Number Signature Date Defendant Attorney Name, P#, Address, Phone Defendant Attorney Name, P#, Address, Phone LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-508 (Rev. 1/12) Front Authority: Completion: Penalty: Workers' Disability Compensation Act 418.853; 2007 MR 4; R418.56 Voluntary Contempt American LegalNet, Inc. www.FormsWorkFlow.com Plaintiff v Last 4 digits of injured worker's social security number: Defendant(s) CERTIFICATE OF RECORDS CUSTODIAN , the undersigned after being sworn, states the following: 1. That I am the Your position of Organization and in such capacity I am the custodian of the business/medical records for this organization. 2. That on ____________________, I was served with a subpoena in connection with this claim, calling for the Date production of business/medical records pertaining to _____________________________________________. 3. 4. That I reviewed the original of the records and made a true and exact copy of the original records and that the attached copies of the original records are true and complete. If submitting medical records, it is the regular practice of this organization to contemporaneously and timely record information concerning the treatment and care of the patient and I have attached the records that have been prepared and kept concerning this patient. Date _______________________________ Signature _________________________________________________ Subscribed and sworn to before me on ________________________, ______________________________ County, Michigan. Date My commission expires ______________________ Date Signature ___________________________________________________ Notary Public AFFIDAVIT OF MAILING/PROOF OF SERVICE I certify that on ___________________ a copy of this subpoena with a witness fee and mileage fee was Date mailed to the other party(ies) or their attorney(s), securely sealed with full-rate postage attached and deposited with the United States Postal Service. personally served. Signature _________________________________________________ Date _______________________________ Subscribed and sworn to before me on ________________________, ______________________________ County, Michigan. Date My commission expires ______________________ Date Signature __________________________________________________ Notary Public WC-508 (Rev. 1/12) Back American LegalNet, Inc. www.FormsWorkFlow.com
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