STATE OF TENNESSEE DAVIDSON COUNTY CIVIL ACTION SUBPOENA DUCES TECUM Circuit Court MEDICAL RECORDS (SEE HIPAA REQUIREMENT BELOW) PLAINTIFF 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 PLACE Circuit Court 523 Mainstream Drive Nashville, TN 37228 ITEMS TO BRING: (OR) This subpoena is being issued on behalf of PLAINTIFF Attorney: Additional List Attached DATE ISSUED DEFENDANT RICHARD R. ROOKER Circuit Court Clerk (NAME, ADDRESS & TELEPHONE NUMBER) BY:___________________________________________ ATTORNEY’S SIGNATURE: DEPUTY CLERK DESIGNEE: ADA Coordinator, Margaret Larobardiere (862-5204) DESIGNEE’S SIGNATURE: Medical Records Requested—HIPAA notice required HIPAA NOTICE on the A copy of this subpoena has been provided to counsel for the patient or the patient by mail or facsimile 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. Submit: Original Witness Copy & File Copy American LegalNet, Inc. www.USCourtForms.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’ signature.) ---------------------------------------------------------------------------------------------------------------------------------------1. I certify that on the date indicated below, I served a copy of this subpoena on the witness stated herein 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.USCourtForms.com