Record Retrieval Request | Magna Legal Services

Your Information

First Name*

Last Name*

Email Address*

Phone

Your Account Representative*

Firm Information

Your Firm Name*

Attorney of Record

Your Firm Address*

Street Address City State ZIP

Case Information

Opposing Counsel

(Attorney and Firm)

Co-Counsel

(Attorney and Firm)

Case Caption

Docket Number

Case Venue

(County and State)

Patient Details

Add the following information for the patient.

First Name*

Middle Initial

Last Name*

Social Security #

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Request authorized by:*

Billing Information

Insurance / Corporate Client

Claim Number

Firm Reference Number

Adjuster

Division

Date of Loss

Provider Details

Click the “Add Provider” button to get started. Note: on smaller devices you can view all entry details by touching the table below and sliding it to the left.

Provider	Provider Contact Name	Provider Address	Provider Phone	Provider Fax	Provider Email	Actions

There are no Providers.

Record Request Details

Select Delivery*

Standard Order

Rush Order

Rush order based on:*

Date*

Add-on Services

Select any services you are interested in and we’ll send you a quote!

Upload File

Drop files here or

Max. file size: 128 MB.

Record Retrieval Form

Medical Record Form