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
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 type or print the information requested. Do not use correction fluid/tape on the forms. This packet contains the following forms: 1. Ex Parte Petition for Order to Release Medical Records 2. Index of Exhibits and Exhibit Cover Page 3. 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 $5,000.00. N.R.S. 199.145. REV 11/16 KV PR2 VISUAL INSTRUCTIONS
INSTRUCTIONS: STEP 1 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 email 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. DO NOT COPY OR FILE THIS PAGE REV 11/16 KV PR2 VISUAL INSTRUCTIONS
1 2 3 4 Code: 3616 Name: Address: Telephone: Email: Self-Represented Litigant 5 6 IN THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 7 IN AND FOR THE COUNTY OF WASHOE 8 9 IN THE MATTER OF THE ESTATE OF: 10 11 12, Deceased. / 13 14 Case No. Dept. No. PR EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS I, a self-represented litigant, allege as follows: 15 1. I am the 17 of Decedent, reside at. (Your Street address, City, State, and Zip Code) 18 19, and (Decedent s name) (Your relationship to Decedent) 16 2. Decedent died on, in (Date, to include, month, day, year) (County where death occurred) 20 and, on the date of death, Decedent was a resident of Washoe County, Nevada. A certified copy of 21 22 23 DECEDENT S DEATH CERTIFICATE OR- OTHER PROOF OF DEATH is attached as Exhibit 1. 24 3. Jurisdiction is proper in this proceeding. 25 4. The names, relationships, ages of minors and residence addresses of all the devisees, 26 27 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, 28 write unknown)): 1 REV 10/2015 ER EX PARTE PETITION MEDICAL RECORDS
Name 1 2 (1) 3 (2) 4 (3) 5 (4) 6 Relationship/Age (if minor) Address (5) 7 (6) 8 5. I am seeking medical records from (list names and addresses of all doctors, health care 9 10 providers, and medical facilities located in Nevada from whom you are seeking records): 11 12 13 14 If more room is needed, attach additional sheets. 15 WHEREFORE, I pray: 16 That the Court make and enter an Order directing the officers of the above named doctors, 17 18 health care providers, and medical facilities to release Decedent s medical records to. 19 (Your name and address, or someone you designate to receive records) 20 I declare, under penalty of perjury under the law of the State of Nevada, that I have read the 21 22 foregoing document and know the contents thereof, and the contents are true of my own 23 knowledge, except for those matters stated therein on information and belief, and, as to those 24 matters, I believe them to be true. 25 This document does not contain the Social Security number of any person. 26 27 Date: Your Signature: Print Your Name: 28 2 REV 4/2015 ER EX PARTE PETITION MEDICAL RECORDS
INSTRUCTIONS: STEP 2 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 11/16 KV PR2 VISUAL INSTRUCTIONS
INDEX OF EXHIBITS Exhibit Number
EXHIBIT EXHIBIT EXHIBIT
INSTRUCTIONS: STEP 3 Complete the Request for Submission as Shown: 1) Print your name, address, telephone number, and email 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. DO NOT COPY OR FILE THIS PAGE REV 11/16 KV PR2 VISUAL INSTRUCTIONS
1 2 3 4 Code: 3860 Name: Address: Telephone: Email: Self-Represented Litigant 5 6 7 IN THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 8 IN AND FOR THE COUNTY OF WASHOE 9 10 11 IN THE MATTER OF THE ESTATE OF: 12 13 14, Deceased. / Case No. Dept. No. PR 15 16 REQUEST FOR SUBMISSION 17 18 I,, request that the (Print your name) 19 20 21 22 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. 23 Date: Signature: 24 25 Print Your Name: 26 27 28 1 REV 09/2014 ER Ex Parte Petition Medical Records RFS
INSTRUCTIONS: STEP 5 Filing the Documents All documents in Probate cases must be electronically filed (E-Filed). To E-File, you must sign up for an E-Flex account by going to https://wceflex.washoecourts.com. You will need to scan the original document and upload to E-Flex. E-Flex is available online or in the Filing Office. Assistance with E-Filing is available at the Filing Office, Law Library, or Self Help Center. The Filing Office and Law Library are located on the first floor of the Courthouse at 75 Court Street, Reno, Nevada, 89501. The Self Help Center is located on the first floor of the Courthouse at One South Sierra Street, Reno, Nevada, 89501. Scanner and copy machines are available at the Law Library. There is a per page charge for copying. DO NOT COPY OR FILE THIS PAGE Any additional documents regarding this decedent shall be filed with this case number. REV JB 01/16 PR2 VISUAL INSTRUCTIONS
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) 328-3250 www.washoecourts.com/lawlib 3rd Wednesday Evening of the Month Arrive by 4:25 p.m. NEVADA LEGAL SERVICES 204 Marsh Avenue Reno, NV 89509 (775) 284-3491 x 237 leave message if necessary http://www.nlslaw.net WASHOE LEGAL SERVICES 299 S. Arlington Avenue Reno, NV 89501 (775) 329-2727 leave message if necessary http://www.washoelegalservices.org Do Not Copy Or File This Page REV 4/15 ER PR2 VISUAL INSTRUCTIONS
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: A person who dies leaving a will. Intestate: A person who dies without leaving a will. Estate: The possessions, property, and debt left by a person at death. Heir: 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: A person who receives a gift of real property by a will. Legatee: A person or organization receiving a gift of an object or money under the terms of the will of a person who has died. Personal Representative: Person(s) who manages the decedent s estate, including an executor, an administrator, a successor personal representative, and/or a special administrator. Intestate Succession: 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. Inventory: 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