Fillable Form 1: PET 2 3 Petitioner, In Proper (Civil Law Self-Help Center)

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Form 1: PET 2 3 Petitioner, In Proper (Civil Law Self-Help Center)

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PET
_____________________________
(Name)
_____________________________
(Address)
_____________________________
(City, State, Zip Code)
_____________________________
(Telephone number/E-mail Address)
Petitioner, In Proper Person
EIGHTH JUDICIAL DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Estate of:
_______________________________________,
Deceased.
Case No.: P
Dept. No.: PC-1
EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS
Petitioner, (your name) ___________________________________________, appearing in
Proper Person, respectfully alleges and shows as follows:
1. Petitioner files this request pursuant to Nevada Revised Statutes 629.061, and
requests that this Court enter an order authorizing the release of medical records of Decedent
(name of person who passed away)_______________________________ (hereinafter “Decedent”).
2. Petitioner is the (your relation to the decedent) ___________________ of Decedent (name of
person who passed away)
________________________ and resides at (your address)
_____________________________________________________________________________
(hereinafter “Petitioner”). A copy of Petitioner’s identification is attached hereto as Exhibit A.
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3. Decedent died on the (day, month, and year of death) ____________________________, in
(county where the decedent died) _________________________ and, on the date of death, Decedent was a
resident of Clark County, Nevada. A certified copy of Decedent’s death certificate is attached
herein as Exhibit B.
4. Jurisdiction is proper in this proceeding.
5. Decedent (check one) did not did execute a Last Will and Testament and/or an
Order for Cremation and Disposition pursuant to NRS 451.655. If Decedent did execute either a
Last Will and Testament or an Order for Cremation and Disposition, it is attached hereto as
Exhibit C.
6. The names, relationships, ages, and residence addresses of all the devisees,
legatees, heirs, and next-of-kin of Decedent, so far as known to Petitioner, are:
(You must include the name, relationship, age (if under 18), and address of (1) decedent’s legally married spouse, (2) all decedent’s children; (3)
all other devisees, legatees, heirs, and next-of kin. List all persons, regardless of age, even if estranged or out of state. Include all addresses; if
unknown, include last known address or state “unknown.”)
Name
Relationship to
Decedent
Age
(If under 18, list age; if over 18,
write “adult.”)
Address
Check here if you have more people to include, and attach a continuation sheet.
7. The devisees, legatees, heirs, and next-of-kin of Decedent who are listed above
either consent to the release of medical records, and I have attached the appropriate Consents to
Order of Release of Medical Records herein; or they have not consented, and an Affidavit in
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Support of Petition for Order For Release of Medical Records explaining their lack of consent is
herein attached as Exhibit D.
8. Petitioner is seeking medical records from:
(List names & addresses of all medical facilities and doctors from whom you are seeking records.)
Address
WHEREFORE, Petitioner prays:
That the Court make and enter its order directing the officers of all the aforementioned
medical facilities and/or doctors to release Decedent’s medical records to
(your name) __________________ of (insert your address)______________________________________.
DATED THIS _____ day of _______________, 20___.
Respectfully submitted,
_____________________________
(signature)
_____________________________
(Your name)
_____________________________
(Your address)
_____________________________
(Your city, state, and zip)
_____________________________
(Your phone number)
_____________________________
(Your email)
PETITIONER, IN PROPER PERSON
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VERIFICATION IN SUPPORT OF
PETITION FOR ORDER TO RELEASE MEDICAL RECORDS
STATE OF NEVADA )
)ss
COUNTY OF CLARK )
(Your name) ________________________, being first duly sworn, declares under penalty of
perjury under the law of the State of Nevada that the foregoing and following is true and correct:
I am the Petitioner in the above-entitled action. I have read the foregoing Ex Parte
Petition for Order to Release Medical Records, and know the contents thereof. The Petition is
true of my own knowledge except as to those matters that are stated on information and belief,
and as to those matters, I believe them to be true.
DATED THIS _____ day of _______________, 20___.
_____________________________
(Signature)
_____________________________
(Your name)
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_____________________________
(Name)
_____________________________
(Address)
_____________________________
(City, State, Zip Code)
_____________________________
(Telephone number/E-mail Address)
In Proper Person
EIGHTH JUDICIAL DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Estate of:
_______________________________________,
Deceased.
Case No.: P
Dept. No.: PC-1
CONSENT TO ORDER TO RELEASE MEDICAL RECORDS
COMES NOW (your name) _________________________________________, (state your
relationship to the decedent)
_________________ of Decedent, whose address is: (your address)
___________________________________________________, being first duly sworn, declare
under penalty of perjury that I am aware of the Ex Parte Petition for Order to Release Medical
Records filed by
(name of person who is filing the petition) _________________________________________
(“Petitioner”) requesting the release of medical records of the above decedent to Petitioner.
I FURTHER ACKNOWLEDGE that I am in agreement with the request to release
medical records to Petitioner and hereby consent to the release.
DATED THIS _____ day of _______________, 20___.
Respectfully submitted,
_____________________________
(Signature)
_____________________________
(Your name)
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ORDR
_____________________________
(Name)
_____________________________
(Address)
_____________________________
(City, State, Zip Code)
_____________________________
(Telephone number/E-mail Address)
Petitioner, In Proper Person
EIGHTH JUDICIAL DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Estate of:
_______________________________________,
Deceased.
Case No.: P
Dept. No.: PC-1
EX PARTE ORDER TO RELEASE MEDICAL RECORDS
The Court, upon reading the verified ex-parte petition of (your name) ____________________________,
and good cause appearing therefore:
IT IS HEREBY ORDERED that the following officers of
(List names & addresses of all medical facilities and doctors from whom you are seeking records).
Address
/ / /
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shall release Decedent’s medical records to (your name) _______________________________ of
(your address) _________________________________________________________________.
DATED this ____ day of ___________, 20_____.
_______________________________
DISTRICT COURT JUDGE
Respectfully submitted,
_____________________________
(Signature)
_____________________________
(Your name)
PETITIONER, IN PROPER PERSON
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EXHIBIT A
(Petitioner’s Identification)
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EXHIBIT B
(Death Certificate)
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EXHIBIT C
(Last Will & Testament)
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EXHIBIT D
(Consents and/or Affidavits in Support of Petition)
County, Nevada
Case No.
I. Part
y
Information
(provide both home and mailing addresses if different)
Plaintiff(s) (name/address/phone): Defendant(s) (name/address/phone):
Attorney (name/address/phone): Attorney (name/address/phone):
II. Nature of Controvers
y
(please select the one most applicable filing type below)
Landlord/Tenant Negligence Other Torts
Unlawful Detainer Auto Product Liability
Other Landlord/Tenant Premises Liability
Intentional Misconduct
Title to Property
Other Negligence
Employment Tort
Judicial Foreclosure Malpractice
Insurance Tort
Other Title to Property Medical/Dental Other Tort
Other Real Property Legal
Condemnation/Eminent Domain Accounting
Other Real Property Other Malpractice
Probate
(select case type and estate value)
Construction Defect Judicial Review
Summary Administration Chapter 40 Foreclosure Mediation Case
General Administration Other Construction Defect Petition to Seal Records
Special Administration Contract Case Mental Competency
Set Aside Uniform Commercial Code Nevada State Agency Appeal
Trust/Conservatorship Building and Construction Department of Motor Vehicle
Other Probate Insurance Carrier Worker's Compensation
Estate Value Commercial Instrument Other Nevada State Agency
Over $200,000 Collection of Accounts Appeal Other
Between $100,000 and $200,000 Employment Contract Appeal from Lower Court
Under $100,000 or Unknown Other Contract Other Judicial Review/Appeal
Under $2,500
Civil Writ Other Civil Filing
Writ of Habeas Corpus Writ of Prohibition Compromise of Minor's Claim
Writ of Mandamus Other Civil Writ Foreign Judgment
Writ of Quo Warrant Other Civil Matters
Signature of initiating party or representative
Civil Writ Other Civil Filing
Date
Business Court filings should be filed using the Business Court civil coversheet.
DISTRICT COURT CIVIL COVER SHEET
(Assigned by Clerk's Office)
See other side for family-related case filings.
Probate
TortsReal Property
Construction Defect & Contract Judicial Review/Appeal
Civil Case Filing Types
N
evada AOC - Research Statistics Uni
t
Pursuant to NRS 3.275
Form PA 201
Rev 3.1
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Form 1: PET 2 3 Petitioner, In Proper (Civil Law Self-Help Center)

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Completed 8 January 2021

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