DISTRICT COURT OF MARYLAND FOR
Located at Case No.
STATE OF MARYLAND vs.
Court Address
City/County
Defendant
Address
Telephone
City, State, Zip
CC #
or
DC-004S (07/2021)
Plaintiff
TAKE NOTE that the medical records regarding, , have been subpoenaed
from located at pursuant to
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing Notice, the subpoena duces tecum, and a copy of section HG § 4-306
was sent by certified mail mailed, first-class postage prepaid, this day of ,
to:
Attorney
Law Firm
Attorney's Phone Number
Healthcare Provider
Patient Name
Healthcare Provider's Address
Attached to this form is a copy of the subpoena duces tecum (DC 4) issued for these records.
Please examine these papers carefully. IF YOU HAVE ANY OBJECTION TO THE PRODUCTION OF THESE
DOCUMENTS, YOU MUST FILE A MOTION FOR A PROTECTIVE ORDER OR A MOTION TO QUASH THE
SUBPOENA ISSUED FOR THESE DOCUMENTS UNDER MARYLAND RULES 2-403, 2-510, OR 4-266 NO
LATER THAN THIRTY (30) DAYS FROM THE DATE THIS NOTICE IS MAILED. For example, a protective order
may be granted if the records are not relevant to the issues in this case, the request unduly invades your privacy, or causes
you specific harm.
If you believe you need further legal advice about this matter, you should consult your attorney.
Name of Party Represented
Attorney's Address
City, State, Zip
Date
Signature of Party Serving/Attorney/Attorney Number
Patient Name
Address
Attorney Name
Address
Attorney Name
Address
Other
Day Month Year
IN COMPLIANCE WITH § 4-306 OF THE HEALTH-GENERAL ARTICLE
ANNOTATED CODE OF MARYLAND
Patient Name
30-DAY CERTIFICATION
I certify that thirty (30) days have elapsed since the above notice was sent. There has been no objection to the
disclosure of the requested documents; or, any objection has been resolved to permit disclosure of the requested
documents.
Do not complete 30-day certification until thirty (30) days after this Notice was mailed.
Requesting Party Name Requesting Party Signature
Date
NOTICE TO
Address
City, State, Zip
City, State, Zip
City, State, Zip
City, State, Zip
the attached subpoena and § 4-306 of the Health - General Article, Annotated Code of Maryland. This subpoena
does or does not (mark one) seek production of mental health records.
Reset
