Follow the steps below upon receipt of any of the following:
-
1.
Subpoenas requesting the production of records without valid consent or requesting
Agency employee testimony Federal or State issued court order,
-
2.
Electronically scan the subpoena or court order and all accompanying documents.
-
-
4.
Email the scanned subpoena without valid consent or court order and the completed Questionnaire
to:
||CHI ARC MOS CRSI SSI Subpoena and Certifications
NOTE: Due to the time sensitivity issue with processing subpoena and court orders, FO and
DDS offices should only fax the subpoena and court order, as well as the questionnaire, if the
office lacks the capability to scan. In such cases, the fax should be sent to (312) 575-4245, Attention: Chicago Privacy
and Disclosure Coordinator.
REQUEST INFORMATION REPRODUCE LOCALLY IF NEEDED
Type of Document (i.e., subpoena, court order, letter):
When did you receive the request? Date: ______/ ______/ ______
What is the name of the legal matter for which records and/or testimony is requested?
(i.e., Doe v. Jones):
Where is the case located? (i.e., Circuit Court of Cook County):
What is the Requestor seeking? (i.e., records, testimony, or both):
About whom (Numberholder) is the Requestor seeking information?:
INFORMATION ABOUT THE REQUESTOR
Requestor's Name: ____________________________________
Requestor's Employer or Firm: _________________
Requestor's Address: _________________________________________
________________________________________________________
Requestor's Phone Number: (_____) ________- ___________
Requestor's Fax Number: (_____) ________- ___________
Requestor's E-mail Address: ___________________________
REFERRAL INFORMATION
Person referring subpoena or court order to the Regional Office:
__________________________________________________
Title of person referring subpoena or court order:
_____________________________________________
Office Location/Code/Component: _________________________
Phone: (_____) ________- ___________