Subpoena (Order To Appear) - Return On Service Form
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1
2STATE OF TENNESSEE
SUBPOENA
CASE FILE NUMBER
DAVIDSON COUNTY
(ORDER TO APPEAR)
CHANCERY COURT
Medical Records (See HIPAA Requirement Below)
PLAINTIFF
DEFENDANT
TO: (Name, Address & Telephone Number of Witness)
Method of Service:
□ Davidson Co. Sheriff
□ Personal Service
□ Out of County Sheriff
You are hereby commanded to appear at the time, date and place specified for the purpose of giving testimony. In addition, if indicated, you
are to bring the items listed. Failure to appear may result in punishment by fine and/or imprisonment as provided by law.
TIME
DATE
ITEMS TO BRING:
PLACE
Chancery Court, Part ________
1 Public Square
Fourth Floor
Nashville, Tennessee 37201
(OR)
___ Additional List Attached
This subpoena is being issued on behalf of
____ Plaintiff
____ Defendant
DATE ISSUED
Attorney: (Name, Address & Telephone Number)
Cristi Scott, Clerk and Master
By:
ATTORNEY’S
SIGNATURE:
AGENT:
Deputy Clerk and Master
AGENT’S
SIGNATURE:
HIPAA NOTICE
A copy of this subpoena has been provided to counsel for the patient or the patient by mail or facsimile on the ________ day
of _______________, 20 ____ so as to allow him/her seven (7) days to:
(A) serve the recipient of the subpoena by facsimile with a written objection to the subpoena, with a copy of the notice by
facsimile to the party that served the subpoena, and
(B) simultaneously file and serve a motion for a protective order consistent with the requirements of T.R.C.P. 26.03, 26.07
and Local Rule § 22.10.
If no objection is made within seven (7) days of the above date, you shall process this subpoena and produce the documents
by the date and time specified in the subpoena. The signature of counsel or party on the subpoena is certification that the above
notice was provided to the patient.
ADA Coordinator, Cristi Scott (862-5710)
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