Legal Services: Request for Deposition - Saint Francis Healthcare System

Saint Francis Medical Center is committed to supporting the legal process while ensuring minimal disruption to patient care. To request the scheduling of a deposition with one of our healthcare providers, please complete the form below in its entirety. Incomplete submissions may result in processing delays. Please note that all depositions must take place on the Saint Francis Medical Center Campus or via Zoom / WebEx unless otherwise approved in writing.

We appreciate your cooperation and look forward to assisting you.

Name of Attorney / Law Firm Requesting Deposition(Required)

Phone Number(Required)

Email Address(Required)

Name of Contact Person / Paralegal

If applicable

Contact Person / Paralegal Email Address

Billing Address for Req. Atty(Required)

Street Address Address Line 2 City State ZIP Code

Opposing Counsel(Required)

Name

Email Address

Phone Number

Click the “+” button to the right of the fields to add additional attorneys

Patient Name(Required)

First Middle Last

Patient DOB(Required)

Patient Date(s) of Service(Required)

SFMC Provider(s) / Colleague(s) to be Deposed(Required)

Type of Case(Required)

"Other" Type of Case Details(Required)

Please describe the type of case

Style of Case and Case Number(Required)

Will Deposition be in Person or Remote?(Required)

Will Deposition be Recorded?(Required)

Approximately How Long Would You Like to Reserve for Deposition?(Required)

Please Provide a Range of Available Dates for All Parties Participating in the Deposition(Required)

Authorization(Required)

Please provide valid HIPAA compliant patient authorization or HIPAA compliant protective order authorizing the use of and disclosure of patient’s Protected Health Information.

Max. file size: 32 MB.

Standard Fee Agreement(Required)

Please note that any party requesting to schedule a deposition will be required to execute a standard fee agreement prior to confirming the deposition date.

I agree

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