Free Microsoft Word - formcir_subpoena - Tennessee

STATE OF TENNESSEE DAVIDSON COUNTY
Circuit Court
PLAINTIFF

DUCES TECUM

SUBPOENA
DEFENDANT
vs.

CIVIL ACTION
DOCKET NO.

MEDICAL RECORDS (SEE HIPAA REQUIREMENT BELOW)

TO:

(NAME, ADDRESS & TELEPHONE NUMBER OF WITNESS)

Method of Service: Davidson County Sheriff Personal Service Out of County Sheriff

You are hereby commanded to appear at the time, date and place specified for the purpose of giving testimony. In Failure to appear may result in contempt of court which addition, if indicated, you are to bring the items listed. could result in punishment by fine and/or imprisonment as provided by law.
TIME DATE ITEMS TO BRING:

PLACE

Circuit Court Clerk 1 Public Square, Room 302 Nashville, TN 37201 (OR)

This subpoena is being issued on behalf of
PLAINTIFF DEFENDANT

Additional List Attached
DATE ISSUED:

Attorney:

(NAME, ADDRESS & TELEPHONE NUMBER)

RICHARD R. ROOKER Circuit Court Clerk
BY___________________________________________
DEPUTY CLERK If you have a disability and require assistance, please contact 862-5204.

ATTORNEY'S SIGNATURE: DESIGNEE: DESIGNEE'S SIGNATURE:

Medical Records Requested-HIPAA notice required

on the

A copy of this subpoena has been provided to counsel for the patient or the patient by mail or facsimile , 20 , so as to allow him/her seven (7) days to: day of

HIPAA NOTICE

(A) Serve the recipient of the subpoena by facsimile with a written objection to the subpoena, with a copy of the notice by facsimile to the party that served the subpoena, and (B) Simultaneously file and serve a motion for a protective order consistent with the requirements of T.R.C.P. 26.03, 26.07 and Local Rule §22.10. If no objection is made within seven (7) days of the above date you shall process this subpoena and produce the documents by the date and time specified in the subpoena. The signature of counsel or party on the subpoena is certification that the above notice was provided to the patient.
Submit: Original, Witness Copy & File Copy

RETURN ON SERVICE
Check one: (1 or 2 are for the return of an authorized officer or attorney; an attorney's return must be sworn to; 3 is for the witness who will acknowledge service and requires the witness' signature.)

---------------------------------------------------------------------------------------------------------------------------------------1. I certify that on the date indicated below, I served a copy of this subpoena on the witness stated herein by: 2. 3.
I failed to serve a copy of this subpoena on the witness because:

I acknowledge being served with this subpoena on the following date:

Sworn to and subscribed before me this ________ day of ______________, 20_____. _____________________________________
Signature of Notary Public or Deputy Clerk My Commission Expires:

DATE OF SERVICE:
SIGNATURE OF WITNESS, OFFICER, ATTORNEY OR ATTORNEY'S DESIGNEE

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