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Ex Parte Petition To Administer A Small Estate And Order To Release Medical Records Form. This is a Nevada form and can be use in Clark County.
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Tags: Ex Parte Petition To Administer A Small Estate And Order To Release Medical Records, Nevada County, Clark
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PET
_____________________________
Name
_____________________________
Address
_____________________________
City, State, Zip Code
_____________________________
Telephone number
IN PROPER PERSON
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DISTRICT COURT
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CLARK COUNTY, NEVADA
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In the Matter of the Estate of: )
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) Case No. P__________
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) Dept. No. PC-1
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Deceased.
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EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS
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Petitioner, ___________________________________________,
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appearing in Proper Person, respectfully alleges and shows as
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follows:
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1.
Petitioner is the ___________________ (how related) of
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Decedent ________________________ (decedent’s name) and resides
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at ____________________________________________________________.
2.
Decedent died on the ____ day of ___________, 20_____,
in _________________________ and, on the date of death, Decedent
was a resident of Clark County, Nevada.
A certified copy of
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Decedent’s death certificate will be submitted upon receipt.
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Jurisdiction is proper in this proceeding.
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3.
The names, relationships, ages of minors and residence
addresses of all the devisees, legatees, heirs, and next-of-kin
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of Decedent, so far as known to Petitioner, are:
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Name
Relationship/Age
Address
(THIS INCLUDES: LEGALLY MARRIED SPOUSE AND ALL CHILDREN, EVEN IF ESTRANGED AND
PETITIONER STATING THEIR RELATIONSHIP)
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4.
Petitioner is seeking medical records from
(list names &
addresses of all medical facilities and doctors from whom you are seeking records)
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________________________________________________________________
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________________________________________________________________
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________________________________________________________________
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________________________________________________________________
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WHEREFORE, Petitioner prays:
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That the Court make and enter its order directing the
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officers of
(list names & addresses of all medical facilities and doctors from whom you are
seeking records)
____________________________________________________
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________________________________________________________________
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________________________________________________________________
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________________________________________________________________
________________________________________________________________
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to release Decedent’s medical records to _______________________
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________________________________________________________________
(name and address).
DATED THIS _____ day of _______________, 20___.
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_____________________________
Signature of Petitioner
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VERIFICATION
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STATE OF NEVADA
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COUNTY OF CLARK
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)ss
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________________________, being first duly sworn, declares
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under penalty of perjury as follows:
I am the Petitioner in the above-entitled action.
I have
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read the foregoing Ex Parte Petition for Order to Release
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Medical Records, and know the contents thereof.
The Petition is
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true of my own knowledge except as to those matters that are
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stated on information and belief, and as to those matters, I
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believe them to be true.
DATED THIS _____ day of _______________, 20___.
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_____________________________
Signature of Petitioner
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Page 3 of 3
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ORDR
_____________________________
Name
_____________________________
Address
_____________________________
City, State, Zip Code
_____________________________
Telephone number
IN PROPER PERSON
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DISTRICT COURT
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CLARK COUNTY, NEVADA
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In the Matter of the Estate of)
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Deceased.
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______________________________)
CASE NO.
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EX PARTE ORDER TO RELEASE MEDICAL RECORDS
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The Court, upon reading the verified ex-parte petition of
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_______________________ (petitioner), and good cause appearing
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therefore:
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IT IS HEREBY ORDERED that the officers of
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all medical facilities and doctors from whom you are seeking records)
(list names & addresses of
_________________
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________________________________________________________________
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________________________________________________________________
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________________________________________________________________
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________________________________________________________________
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________________________________________________________________
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///
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///
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///
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shall release the Decedent’s medical records to ________________
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_______________________________________________________________.
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DATED this ____ day of ___________, 20_____.
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_______________________________
DISTRICT COURT JUDGE
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Respectfully submitted,
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By:
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___________________
(signature)
___________________
(print name)
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IN PROPER PERSON
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Page 2 of 2
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