State of Michigan Department of Licensing and Regulatory Affairs Michigan Administrative Hearing / Workers222 Compensation Agency P.O. Box 30016, Lansing, MI 48909 SUBPOENA FOR PRODUCTION OF RECORDS (and/or) WITNESS SUBPOENA PlaintiffLast 4 digits of injured worker222s social security number: v Defendant(s) TO: YOU ARE ORDERED: 1.to produce on or before the following records, papers, books and documents, ormake the materials reasonably available for copying when received: to appear personally before on: 2.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 WORKERS222 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) Representing P Number Email Telephone Number Street Address City State ZIP Code 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. This subpoena must be signed by an Attorney of Record, Magistrate, Workers222 Compensation Agency Director, or Chair of the Michigan Compensation Appellate Commission. Name (please print or type) P NumberSignatureDate Plaintiff Attorney Name, P#, Address, Phone 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. Authority: Completion: Penalty: Workers222 Disability Compensation Act 418.853; 2007 MR 4; R418.56Voluntary Contempt WC-508 (Rev. /1) Front American LegalNet, Inc. www.FormsWorkFlow.com PlaintiffLast 4 digits of injured worker222s social security number: v Defendant(s) CERTIFICATE OF RECORDS CUSTODIAN , the undersigned after being sworn, states the following: 1.That I am the ofYour p osition Or g anization and in such capacity I am the custodian of the business/medical records for this organization. That on , I was served with a subpoena in connection with this claim, calling for the Date 2. production of business/medical records pertaining to . 3.That I reviewed the original of the records and made a true and exact copy of the original records and that theattached copies of the original records are true and complete.4.If submitting medical records, it is the regular practice of this organization to contemporaneously and timely recordinformation concerning the treatment and care of the patient and I have attached the records that have beenprepared and kept concerning this patient.Signature Date Subscribed and sworn to before me on , County, Michigan. Date My commission expires Signature DateNotary 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 Signature DateNotary Public WC-508 (Rev. /1) Back American LegalNet, Inc. www.FormsWorkFlow.com