STATE OF TENNESSEE SHELBY COUNTY CIRCUIT COURT You are hereby commanded to summon: personally to be and appear on , at at in the City of Memphis, then and there to testify and give evidence on behalf of in the case of against This you will in no wise omit, under the penalty prescribed by law. Herein fail not, and have you then and there this Writ. Tested and Issued this day of , 20 FOR AMERICANS WITH DISABILITIES ACT (ADA) ASSISTANCE ONLY, CALL (901) 222-2341 By: D.C. 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 and 26.07. 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. Attorney or Party Signature for HIPAA notice to testifySUBPOENA to take deposition duces tecum for medical records* Docket Number * (see HIPAA requirement below) Shelby County Sheriff Commissioner of Insurance ($) Secretary of State ($) Other TN County Sheriff ($) Private Process Server OtherMethod of Service:($) Attach Required Fees , Clerk American LegalNet, Inc. www.FormsWorkFlow.com RETURN OF SERVICE OF SUBPOENA I HEREBY CERTIFY THAT I HAVE SERVED THE WITHIN SUBPOENA: By delivering on the day of , 20 at M. a copy of the subpoena to the following Witness at By: Signature of person accepting service Sheriff or other authorized person to serve process RETURN OF NON-SERVICE OF SUBPOENA I HEREBY CERTIFY THAT I HAVE NOT SERVED THE WITHIN SUBPOENA: To the named Witness because is (are) not to be found in this County after diligent search and inquiry for the following reason(s): This day of , 20. By: Sheriff or other authorized person to serve process Docket No:IN THE (CIRCUIT/CHANCERY) COURT OF TENNESSEE FOR THE THIRTIETH JUDICIAL DISTRICT AT MEMPHIS SUBPOENA VSPlaintiffDefendantAttorney/Pro SeTelephone Number American LegalNet, Inc. www.FormsWorkFlow.com