STATE OF TENNESSEE DAVIDSON COUNTY Circuit Court PLAINTIFF SUBPOENA TESTIMONY/PRODUCTION REQUIRED (SEE NOTICE BELOW) MEDICAL RECORDS (SEE HIPAA REQUIREMENT BELOW) CIVIL ACTION DOCKET NO. DEFENDANT vs. 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 addition, if indicated, you are to bring the items listed. Failure to appear may result in contempt of Court which 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 To request an ADA accommodation, please contact Dart Gore at 880-3309. ATTORNEY'S SIGNATURE: DESIGNEE: DESIGNEE'S SIGNATURE: Testimony/Production required. TESTIMONY/PRODUCTION NOTICE The failure to serve an objection to this Subpoena within twenty-one (21) days after the day of service of the Subpoena waives all objections to the Subpoena, except the right to seek the reasonable costs for producing books, papers, documents, electronically stored information, or tangible things. Medical Records Requested ­ HIPAA notice required. 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 twenty-one (21) days to: (A) (B) 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 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 twenty-one (21) 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 [Revised 7/23/13] 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; the witness who will acknowledge service and requires the witness' signature.) 3 is for ---------------------------------------------------------------------------------------------------------------------------------------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 following date: Sworn to and subscribed before me, this ________ day of _________________, 20____. DATE OF SERVICE: SIGNATURE OF WITNESS, OFFICER, ATTORNEY OR ATTORNEY'S DESIGNEE: Signature of: Notary Public or Deputy Clerk My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com