Ex Parte Petition for Order to Release Medical Records {3616} | Pdf Fpdf Doc Docx | Nevada

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Ex Parte Petition for Order to Release Medical Records {3616} | Pdf Fpdf Doc Docx | Nevada

Ex Parte Petition for Order to Release Medical Records {3616}

This is a Nevada form that can be used for Family within County, Washoe, District Court.

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Code: 3616 Name: __________________________ Address: __________________________ ____________________________________ Telephone: __________________________ Email: __________________________ Self-Represented Litigant IN THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE IN THE MATTER OF THE ESTATE OF: _______________________________________, Deceased. / Case No. ___________________ Dept. No. PR EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS I, a self-represented litigant, allege as follows: 1. I am the of Decedent, (Your relationship to Decedent) (Decedent's name) , and 16 17 18 19 20 reside at (Your Street address, City, State, and Zip Code) . 2. Decedent died on (Date, to include, month, day, year) , in (County where death occurred) and, on the date of death, Decedent was a resident of Washoe County, Nevada. A certified copy of 21 22 23 24 25 26 27 28 DECEDENT'S DEATH CERTIFICATE ­OR"Exhibit 1". 3. Jurisdiction is proper in this proceeding. OTHER PROOF OF DEATH is attached as 4. The names, relationships, ages of minors and residence addresses of all the devisees, legatees, heirs, and next-of-kin of Decedent, as known to me, are (include spouse, parents, siblings, and all children of Decedent, even if estranged or out of State (if address is unknown, write unknown)): 1 REV 10/2015 ER American LegalNet, Inc. www.FormsWorkFlow.com EX PARTE PETITION ­ MEDICAL RECORDS 1 2 3 4 5 6 7 Name (1) (2) (3) (4) (5) (6) Relationship/Age (if minor) Address 8 5. I am seeking medical records from (list names and addresses of all doctors, health care 9 10 11 12 13 14 15 providers, and medical facilities located in Nevada from whom you are seeking records): If more room is needed, attach additional sheets. WHEREFORE, I pray: 16 That the Court make and enter an Order directing the officers of the above named doctors, 17 18 19 20 health care providers, and medical facilities to release Decedent's medical records to . (Your name and address, or someone you designate to receive records) I declare, under penalty of perjury under the law of the State of Nevada, that I have read the 21 22 23 24 25 26 27 28 foregoing document and know the contents thereof, and the contents are true of my own knowledge, except for those matters stated therein on information and belief, and, as to those matters, I believe them to be true. This document does not contain the Social Security number of any person. Date: _________________ Your Signature: _________________________________ Print Your Name: _________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com REV 4/2015 ER EX PARTE PETITION ­ MEDICAL RECORDS

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