Motion to Quash SUBPOENA DUCES TECUM FOR HEALTH RECORDS
LAW/CHANCERY NO. __________________
VIRGINIA: IN THE ___________________________________________________________CIRCUIT COURT
Name of court ________________________________________________________________________________________________ Address of court ___________________________________ Telephone number (optional)
_________________________________________ v. ______________________________________________
Plaintiff / Petitioner Defendant / Respondent
________________________________________________________,
Name of \person filing the motion to quash
by counsel
pro se, pursuant
to Rules 4:1 and 4:9(c) of the Supreme Court of Virginia and the Virginia Health Records Privacy Actimoves this Court to quash or modify the subpoena duces tecum requested by _______________________________________________________________________________________
Name of party requesting or causing issuance of the subpoena
for the health care recordsii of: __________________________________________________________________________________________
Name and address of individual __________________________ Date of birth
______________________
Social Security Number (optional)
_______________________________________________,
Other identifying information if needed
issued to: __________________________________________________________________________________________
Name of doctor or health care entity with address
on the following grounds:
[This section can be expanded to include the necessary information to adequately describe the grounds.]
WHEREFORE, _________________________________________moves the Court to quash or
Name of person filing the motion to quash
amend the subpoena duces tecum issued in this matter. Page 1 of 2
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________________________________
Requesting party or counsel
_________________________________________________________________________________________
Name and address of law Firm or Pro Se party ______________________________________________________ Printed name of attorney ____________________________ Telephone number ____________________________ Virginia State Bar No. ______________________________ E-mail address (optional)
_____________________________ Fax number
CERTIFICATE OF SERVICE
I certify that a true copy of the: MOTION TO QUASH SUBPOENA DUCES TECUM FOR HEALTH RECORDS was and/or mailed, faxed_________________ , _____________
Fax Number Time
electronically mailed, by agreement,
hand-delivered on ________________________________________ toiii: Pro Se / Nonparty Witness (at the address stated on Page 1); Doctor or Health Care Entity (at the address on Page 1); Opposing Counsel / Pro Se (not the individual) (at the below address)
__________________________________________________________________________________________
Name and address of opposing counsel / Pro Se / nonparty witness
Other ______________________________________________________________________________
_________________________________________________ Person Certifying
i
Va. Code § 32.1-127.1:03 (amendments effective March 12, 2004) Va. Code § 32.1-127.1:03(H)(6) test to determine good cause for release of subpoenaed records. iii Virginia Supreme Court Rules 1:12 ,1:7 (amendment effective October 15, 2003) and 4:15(e) (amendment effective January 1, 2003).
ii
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