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Order Date:
 Court date:

1202 E 17Th St, Ste 204, Santa Ana, CA 92701
Phone: (714) 619-2444 Fax: (714) 619-2445
records@primesolutionsus.com
www.primesolutionsus.com

Add to Existing Order:      ADJ

REQUESTER

* Firm Name: Attorney:
        Street: City: State: Zip Code:
       * Phone: Fax:
    Authorized Requesters' Name:     Signature:

CLAIMANT

   Name:
      AKA:
     DOB:    SSN:
    ADJ#:
DOI(s) From:     DOI(s) To:

EMPLOYER

  Name:
  Street:
     City: State: Zip Code:
  Phone:

INSURANCE / BILLING

Name: Claim Number:
 Street: City: State: Zip Code:
Phone: Fax:

COPY / SERVE LOCATIONS

1        Name: Record Type:
          Street: City: State: Zip Code:
          Phone: Fax: DATE RANGE:
2        Name: Record Type:
          Street: City: State: Zip Code:
          Phone: Fax: DATE RANGE:
3        Name: Record Type:
          Street: City: State: Zip Code:
          Phone: Fax: DATE RANGE:

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Submit Records Request Form by email to records@primesolutionsus.com or fax (714)619-2445