Ex Parte Petition For Order To Release Medical Records

1 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center PET (Name) (Address) (City, State, Zip Code) (Telephone number/E-mail Address) Petitioner, In Proper Person EIGHTH JUDICIAL DISTRICT COURT CLARK COUNTY, NEVADA In the Matter of the Estate of: , Deceased. Case No.: P Dept. No.: PC-1 EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS Petitioner, (your name) , appearing in Proper Person, respectfully alleges and shows as follows: 1. Petitioner files this request pursuant to Nevada Revised Statutes 629.061, and requests that this Court enter an order authorizing the release of medical records of Decedent (name of person who passed away) (hereinafter 223Decedent224). 2. Petitioner is the (your relation to the decedent) of Decedent (name of person who passed away) and resides at (your address) (hereinafter 223Petitioner224). A copy of Petitioner222s identification is attached hereto as Exhibit A. American LegalNet, Inc. www.FormsWorkFlow.com 2 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center 3. Decedent died on the (day, month, and year of death) , in (county where the decedent died) and, on the date of death, Decedent was a resident of Clark County, Nevada. A certified copy of Decedent222s death certificate is attached herein as Exhibit B. 4. Jurisdiction is proper in this proceeding. 5. Decedent (check one) did not did execute a Last Will and Testament and/or an Order for Cremation and Disposition pursuant to NRS 451.655. If Decedent did execute either a Last Will and Testament or an Order for Cremation and Disposition, it is attached hereto as Exhibit C. 6. The names, relationships, ages, and residence addresses of all the devisees, legatees, heirs, and next-of-kin of Decedent, so far as known to Petitioner, are: (You must include the name, relationship, age (if under 18), and address of (1) decedent222s legally married spouse, (2) all decedent222s children; (3) all other devisees, legatees, heirs, and next-of kin. List all persons, regardless of age, even if estranged or out of state. Include all addresses; if unknown, include last known address or state 223unknown.224) Name Relationship to Decedent Age (If under 18, list age; if over 18, write 223adult.224) Address Check here if you have more people to include, and attach a continuation sheet. 7. The devisees, legatees, heirs, and next-of-kin of Decedent who are listed above either consent to the release of medical records, and I have attached the appropriate Consents to Order of Release of Medical Records herein; or they have not consented, and an Affidavit in American LegalNet, Inc. www.FormsWorkFlow.com 3 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center Support of Petition for Order For Release of Medical Records explaining their lack of consent is herein attached as Exhibit D. 8. Petitioner is seeking medical records from: (List names & addresses of all medical facilities and doctors from whom you are seeking records.) Medical Facility Address WHEREFORE, Petitioner prays: That the Court make and enter its order directing the officers of all the aforementioned medical facilities and/or doctors to release Decedent222s medical records to (your name) of (insert your address). DATED THIS day of , 20. Respectfully submitted, (signature) (Your name) (Your address) (Your city, state, and zip) (Your phone number) (Your email) PETITIONER, IN PROPER PERSON American LegalNet, Inc. www.FormsWorkFlow.com 4 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center VERIFICATION IN SUPPORT OF PETITION FOR ORDER TO RELEASE MEDICAL RECORDS STATE OF NEVADA ) )ss COUNTY OF CLARK ) (Your name) , being first duly sworn, declares under penalty of perjury under the law of the State of Nevada that the foregoing and following is true and correct: I am the Petitioner in the above-entitled action. I have read the foregoing Ex Parte Petition for Order to Release Medical Records, and know the contents thereof. The Petition is true of my own knowledge except as to those matters that are stated on information and belief, and as to those matters, I believe them to be true. DATED THIS day of , 20. (Signature) (Your name) American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center (Name) (Address) (City, State, Zip Code) (Telephone number/E-mail Address) In Proper Person EIGHTH JUDICIAL DISTRICT COURT CLARK COUNTY, NEVADA In the Matter of the Estate of: , Deceased. Case No.: P Dept. No.: PC-1 CONSENT TO ORDER TO RELEASE MEDICAL RECORDS COMES NOW (your name) , (state your relationship to the decedent) of Decedent, whose address is: (your address) , being first duly sworn, declare under penalty of perjury that I am aware of the Ex Parte Petition for Order to Release Medical Records filed by (name of person who is filing the petition) (223Petitioner224) requesting the release of medical records of the above decedent to Petitioner. I FURTHER ACKNOWLEDGE that I am in agreement with the request to release medical records to Petitioner and hereby consent to the release. DATED THIS day of , 20. Respectfully submitted, (Signature) (Your name) American LegalNet, Inc. www.FormsWorkFlow.com 1 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center ORDR (Name) (Address) (City, State, Zip Code) (Telephone number/E-mail Address) Petitioner, In Proper Person EIGHTH JUDICIAL DISTRICT COURT CLARK COUNTY, NEVADA In the Matter of the Estate of: , Deceased. Case No.: P Dept. No.: PC-1 EX PARTE ORDER TO RELEASE MEDICAL RECORDS The Court, upon reading the verified ex-parte petition of (your name) , and good cause appearing therefore: IT IS HEREBY ORDERED that the following officers of (List names & addresses of all medical facilities and doctors from whom you are seeking records). Medical Facility Address / / / American LegalNet, Inc. www.FormsWorkFlow.com 2 of 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center shall release Decedent222s medical records to (your name) of (your address) . DATED this day of , 20. DISTRICT COURT JUDGE Respectfully submitted, (Signature) (Your name) PETITIONER, IN PROPER PERSON American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center EXHIBIT A (Petitioner222s Identification) American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center EXHIBIT B (Death Certificate) American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center EXHIBIT C (Last Will & Testament) American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 251 4/11/17 Civil Law Self - Help Center EXHIBIT D (Consents and/or Affidavits in Support of Petition) American LegalNet, Inc. www.FormsWorkFlow.com County, NevadaCase No. I. Part y Information (provide both home and mailing addresses if different)Plaintiff(s) (name/address/phone):Defendant(s) (name/address/phone):Attorney (name/address/phone):Attorney (name/address/phone):II.Nature of Controvers y (please select the one most applicable filing type below)Landlord/TenantNegligenceOther TortsUnlawful DetainerAuto Product LiabilityOther Landlord/TenantPremises Liability Intentional MisconductTitle to PropertyOther NegligenceEmployment TortJudicial ForeclosureMalpracticeInsurance TortOther Title to PropertyMedical/DentalOther TortOther Real PropertyLegalCondemnation/Eminent DomainAccountingOther Real PropertyOther MalpracticeProbate (select case type and estate value)Construction DefectJudicial ReviewSummary AdministrationChapter 40Foreclosure Mediation CaseGeneral AdministrationOther Construction DefectPetition to Seal RecordsSpecia