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CITYWIDE SCANNING SERVICE, INC.
3010 WILSHIRE BLVD, STE 225
TEL.: (213) 353-0500 | FAX: (213) 377-5238 |
orders@citywidescanning.com

Date requested
Date Due

WC Request

PI Request

Other

Priority

Add to Existing

Applicant's Information

WCAB Case #:

Last, First Name and AKA:

Address:

DOB: SSN: DOI: CT:

Employer/Defendant Information

Employer/Name: Location/Branch:

Address:

Tel, Fax, E-mail:

I would like to Subpoena records from the employer.

Responsible Party/Carrier Information

Name: Claim #:

Adjuster: Tel, Fax, E-mail:

Address:

I would like to Subpoena records from the Carrier.

Requestor/ Applicant's Attorney

Firm*:

Required field

Requested by*:

Required field

Address: Tel, Fax, E-mail:

Deliver Records in:

Paper

Secure E-mail

Online access

Defense Attorney Information

Primary Treating Physician

Name:

Address:

Deliver Additional Set Electronic Records to

Name:

Address:

Tel, Fax, E-mail

Locations Requested
Type Records: [M] Medical, [C] Claim File, [E] Employer, [I] Insurance, [O] Other

TYPE	FACILITY	ADDRESS	TELEPHONE	CONTACT

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Citywide Scanning customarily requests a Notice of Representation for new orders.
Please upload any necessary documents to process the order, such as NOR, Authorization to Release medical records, Substitution of Attorney and others.

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