STATE OF TENNESSEE DAVIDSON COUNTY CHANCERY COURT SUBPOENA (ORDER TO APPEAR) CASE FILE NUMBER Medical Records (See HIPAA Requirement Below) DEFENDANT PLAINTIFF TO: (Name, Address & Telephone Number of Witness) Method of Service: □ Davidson Co. 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 addition, if indicated, you are to bring the items listed. Failure to appear may result in punishment by fine and/or imprisonment as provided by law. TIME ITEMS TO BRING: DATE PLACE Chancery Court, Part ________ 1 Public Square Fourth Floor Nashville, Tennessee 37201 (OR) ___ Additional List Attached This subpoena is being issued on behalf of ____ Plaintiff ____ Defendant DATE ISSUED Attorney: (Name, Address & Telephone Number) Cristi Scott, Clerk and Master By: ATTORNEY’S SIGNATURE: AGENT: Deputy Clerk and Master AGENT’S SIGNATURE: HIPAA NOTICE A copy of this subpoena has been provided to counsel for the patient or the patient by mail or facsimile on the ________ day of _______________, 20 ____ so as to allow him/her seven (7) days to: (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. ADA Coordinator, Cristi Scott (862-5710) American LegalNet, Inc. www.FormsWorkFlow.com 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’s signature.) 1. ___ I certify that on the date indicated below I served a copy of this subpoena on the witness stated above by _____________________________________________________________________________________________ 2. ___ I failed to serve a copy of this subpoena on the witness because ________________________________________________________________________________________________ 3. ___ I acknowledge being served with this subpoena on the date indicated below: Sworn to and subscribed before me on this ____ day of DATE OF SERVICE _______________________, 20 ___. Signature of ___ Notary Public or ___ Deputy Clerk SIGNATURE OF WITNESS, OFFICER, ATTORNEY OR ATTORNEY’S AGENT My Commission Expires: Submit three: Original, Witness Copy & File Copy American LegalNet, Inc. www.FormsWorkFlow.com