EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS

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1 EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS PR 2 The District Court Filing Office is located on the first floor at: 75 Court Street Reno, NV 89501

2 EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS PACKET PR-2 INSTRUCTIONS FOR COMPLETING FORMS CAREFULLY READ ALL INSTRUCTIONS BEFORE STARTING TO FILL OUT ANY OF THE FORMS Use black or blue ink only. Neatly print the information requested. Do not use correction fluid/tape on the forms. This packet contains the following forms: 1. Civil Cover Sheet 2. Ex Parte Petition for Order to Release Medical Records 3. Index of Exhibits and Exhibit Cover Page 4. Request for Submission Do Not Copy Or File This Page The penalty for willfully making a false statement under penalty of perjury is a minimum of 1 year, and a maximum of 4 years in prison, in addition to a fine of not more than $5, N.R.S REV 4/15 ER PR2 VISUAL INSTRUCTIONS

3 INSTRUCTIONS: STEP 1 Complete the Civil Cover Sheet as shown: 1) Print the Decedent s name under the heading Plaintiff. 2) Print your name, address, and telephone number under the heading Attorney. 3) Check the box labeled Other Probate 3) Date and sign the form. Do Not Copy Or File This Page REV 4/15 ER PR2 VISUAL INSTRUCTIONS

4 DISTRICT COURT CIVIL COVER SHEET WASHOE Case No. (Assigned by Clerk's Office) I. Party Information (provide both home and mailing addresses if different) Plaintiff(s) (name/address/phone): County, Nevada Defendant(s) (name/address/phone): Attorney (name/address/phone): Attorney (name/address/phone): II. Nature of Controversy (please select the one most applicable filing type below) Civil Case Filing Types Real Property Torts Landlord/Tenant Negligence Other Torts Unlawful Detainer (UD) Auto (VP) Product Liability (PL) Other Landlord/Tenant (LT) Premises Liability (SF) Intentional Misconduct (IM) Title to Property Other Negligence (NO) Employment Tort (WT) Judicial Foreclosure (FC) Malpractice Insurance Tort (IN) Other Title to Property (OT) Medical/Dental (MD) Other Tort (TO) Other Real Property Legal (LG) Condemnation/Eminent Domain (CD) Accounting (AG) Other Real Property (RO) Other Malpractice (MG) Probate Construction Defect & Contract Judicial Review/Appeal Probate (select case type and estate value) Construction Defect Judicial Review Summary Administration (SU) Chapter 40 (CQ) Foreclosure Mediation Case (FO) General Administration (FA) Other Construction Defect (CF) Petition to Seal Records (PS) Special Administration (SL) Contract Case Mental Competency (MT) Set Aside (SE) Uniform Commercial Code (UN) Nevada State Agency Appeal Trust/Conservatorship (TN) Building and Construction (BC) Department of Motor Vehicle (DM) Other Probate (OP) Insurance Carrier (BF) Worker's Compensation (SI) Estate Value Commercial Instrument (CI) Other Nevada State Agency (ON) Over $200,000 Collection of Accounts (CT) Appeal Other Between $100,000 and $200,000 Employment Contract (EC) Appeal from Lower Court (CA) Under $100,000 or Unknown Other Contract (CO) Other Judicial Review/Appeal (AO) Under $2,500 Civil Writ Other Civil Filing Civil Writ Other Civil Filing Writ of Habeas Corpus (HB) Writ of Prohibition (WP) Compromise of Minor's Claim (CM) Writ of Mandamus (WM) Other Civil Writ (WO) Foreign Judgment (FJ) Writ of Quo Warrant (WQ) Other Civil Matters (GC) Business Court filings should be filed using the Business Court civil coversheet. Date Signature of initiating party or representative Nevada AOC - Research Statistics Unit Pursuant to NRS \ Rev 3.1 \ July 1, 2014 Form PA 201 Rev 3.1

5 INSTRUCTIONS: STEP 2 Do Not Copy Or File This Page Complete the Ex Parte Petition for Order to Release Medical Records as shown: A certified copy of the Decedent s death certificate OR other proof of death must be attached as Exhibit 1. 1) Print your name, address, telephone number, and address. You will be assigned a case number when you file the Petition with the Court. 2) Print or type the Decedent s name. Complete pages 1-2 following the instructions on each page. REV 10/15 ER PR2 VISUAL INSTRUCTIONS

6 Code: 3616 Name: Address: Telephone: Self-Represented Litigant IN THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE IN THE MATTER OF THE ESTATE OF:, Case No. Deceased. / Dept. No. PR EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS I, a self-represented litigant, allege as follows: 1. I am the of Decedent,, and (Your relationship to Decedent) (Decedent s name) reside at. (Your Street address, City, State, and Zip Code) 2. Decedent died on, in (Date, to include, month, day, year) (County where death occurred) and, on the date of death, Decedent was a resident of Washoe County, Nevada. A certified copy of DECEDENT S DEATH CERTIFICATE OR- OTHER PROOF OF DEATH is attached as Exhibit Jurisdiction is proper in this proceeding. 4. The names, relationships, ages of minors and residence addresses of all the devisees, legatees, heirs, and next-of-kin of Decedent, as known to me, are (include spouse, parents, siblings, and all children of Decedent, even if estranged or out of State (if address is unknown, write unknown)): 1 REV 10/2015 ER EX PARTE PETITION MEDICAL RECORDS

7 (1) (2) (3) Name Relationship/Age (if minor) Address (4) (5) (6) 5. I am seeking medical records from (list names and addresses of all doctors, health care providers, and medical facilities located in Nevada from whom you are seeking records): If more room is needed, attach additional sheets. WHEREFORE, I pray: That the Court make and enter an Order directing the officers of the above named doctors, health care providers, and medical facilities to release Decedent s medical records to (Your name and address, or someone you designate to receive records) I declare, under penalty of perjury under the law of the State of Nevada, that I have read the foregoing document and know the contents thereof, and the contents are true of my own knowledge, except for those matters stated therein on information and belief, and, as to those matters, I believe them to be true. This document does not contain the Social Security number of any person Date: Your Signature: Print Your Name: REV 4/2015 ER 2 EX PARTE PETITION MEDICAL RECORDS

8 INSTRUCTIONS: STEP 3 Complete the Index of Exhibits and Exhibit Cover Sheet(s) as shown: 1) Write the exhibit number, number of pages (not including the Exhibit Cover Page), and a description for each exhibit. If more space is needed, attach additional sheets. 2) Attach the Index of Exhibits to the document after the last page of the document, before any exhibits. 3) For each exhibit, create a numbered Exhibit Cover Page. 4) Write the exhibit number on the Exhibit Cover Page. 5) Attach the correct Exhibit Cover Page to the front of each exhibit. 6) Attach your exhibits in the order listed on the Index of Exhibits. REV 4/15 ER PR2 VISUAL INSTRUCTIONS

9 INDEX OF EXHIBITS Exhibit Number

10 EXHIBIT EXHIBIT EXHIBIT

11 INSTRUCTIONS: STEP 4 Complete the Request for Submission as shown: 1) Print your name, address, telephone number, and address. 2) Print the Decedent s name. 3) Print your name. 4) Print the date the Petition was filed. 5) Date, sign, and print your name. REV 4/15 ER PR2 VISUAL INSTRUCTIONS

12 Code: 3860 Name: Address: Telephone: Self-Represented Litigant IN THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN THE MATTER OF THE ESTATE OF: IN AND FOR THE COUNTY OF WASHOE , Case No. Deceased. / Dept. No. PR REQUEST FOR SUBMISSION I,, request that the (Print your name) Ex Parte Petition for Order to Release Medical Records that was filed on (Date Petition was filed) be submitted to the Court for decision. This document does not contain the Social Security Number of any person. Date: Signature: Print Your Name: REV 09/2014 ER 1 Ex Parte Petition Medical Records RFS

13 INSTRUCTIONS: STEP 5 Copying and Filing Documents Take the original and two (2) copies of the completed documents to the Filing Clerk's Office to be filed. Each document must be stapled. The Filing Clerk s Office will not accept forms that are not stapled. The Filing Clerk s Office is located on the first floor of the courthouse at 75 Court Street, Reno, NV, Room 131. A copy machine is available at the Law Library located on the first floor of the courthouse at 75 Court Street, Reno, NV (to the left of the Filing Clerk s Office). There is a per page charge to use the copy machine. The Filing Clerk s Office will keep the original documents and return file-stamped copies to you. Please make sure to keep copies of all the documents you file for your personal records. STOP The case will be closed upon entry of the Court s Order. Do Not Copy Or File This Page Any additional documents regarding this decedent shall be filed with this case number. REV 4/15 ER PR2 VISUAL INSTRUCTIONS

14 Legal Assistance The information in this packet is provided as a courtesy only. This packet is not a substitute for the advice of an attorney. Counsel is always recommended for legal matters. If you do not have an attorney, you are encouraged to seek the advice of a licensed attorney or visit the Family Court Self Help Center, which is located at One South Sierra Street, Reno, NV. The Family Court Self Help Center cannot give legal advice but can give information regarding court procedures. You may also wish to speak with a lawyer at no cost through the Law Library s Lawyer in the Library program, or to seek assistance from other free or reduced-cost legal resources in the area, to include: LAWYER IN THE LIBRARY First Floor (to the left of the filing office) of the courthouse located at: 75 Court Street, Reno, NV. (775) rd Wednesday Evening of the Month Arrive by 4:25 p.m. NEVADA LEGAL SERVICES 204 Marsh Avenue Reno, NV (775) x 237 leave message if necessary WASHOE LEGAL SERVICES 299 S. Arlington Avenue Reno, NV (775) leave message if necessary Do Not Copy Or File This Page REV 4/15 ER PR2 VISUAL INSTRUCTIONS

15 The following definitions and explanations are only to be used as general guidance. The definitions provided do not explain the entire legal meaning or importance of the terms. A private attorney, licensed to practice in the State of Nevada, or a representative of one of the local legal resource agencies can provide you with a full explanation of the terms. Testate: Intestate: Estate: Heir: A person who dies leaving a will. A person who dies without leaving a will. The possessions, property, and debt left by a person at death. Persons, including the surviving spouse and the state, who are entitled by intestate succession to the property of a person who has died. Beneficiary: A broad definition for any person or entity who is to receive assets or profits from an estate, a trust, an insurance policy or any legal document in which there is distribution. Devisee: Legatee: Personal Representative: Intestate Succession: Inventory: A person who receives a gift of real property by a will. A person or organization receiving a gift of an object or money under the terms of the will of a person who has died. Person(s) who manages the decedent s estate, including an executor, an administrator, a successor personal representative, and/or a special administrator. The inheritance of an ancestor's property according to the laws that are applied when the deceased does not have a valid will. Chapter 134 of Nevada Revised Statutes. A description of the decedent s assets and debts. An inventory must include all the decedent s estate, wherever situated, that is subject to the jurisdiction of the court. The inventory must contain: - The entire estate of the decedent. - A statement of all receivables, partnerships, and other interests, bonds, mortgages, notes, and other securities for the payment of money, belonging to the decedent, specifying the name of the debtor in each security, the date, the sum originally payable, any endorsements with their dates, and the sum which, in the judgment of the appraiser, may be collectible on each debt, interest or security. - Mortgages of any kind on the real and personal property of the estate. The inventory must show: - So far as can be determined, what portion of the estate is community property and what portion is the separate property of the decedent. - An account of all money belonging to the decedent that has come into the possession of the personal representative. Do Not Copy Or File This Page

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