Form 6-23

Subpoena to Compel Production of Protected Health Information of [name of patient]

Issued in the Name of the State of Texas

You, [name of witness], are hereby commanded to appear at [address, city, county], Texas, on [date] at [time] and produce at that time and place the following documents or tan­gible things in your possession, custody, or control relating to the case entitled “[style of case]” and filed under Cause No. [number], in the [designation] Court of [county] County, Texas: [specify].

This subpoena is based on a qualified protective court order issued by the [designation] Court of [county] County, Texas. A certified copy of the qualified protective order is attached to this subpoena. This subpoena is issued at the instance of [name of party], [Petitioner/Respondent/Intervenor] in the above-referenced case [include if applicable: , by and through [his/her/its] attorney of record, [name of attorney]].

Failure of any person without adequate excuse to obey a subpoena served on that person may be deemed a contempt of the court from which the subpoena is issued or a district court in the county in which the subpoena is served, and may be punished by fine or confinement, or both.

This subpoena is issued on [date] by:

   
[Name of person issuing subpoena]
[Capacity]
[Address]
[Telephone]
[Telecopier]

Proof of Service

I, [name of witness], accept service of the attached subpoena and will appear at the time and place directed in the subpoena.

Date: ___________________________________.

   
(Signature of witness)

I, __________________________________, am over the age of eighteen years. I am not a party in the above-entitled and -numbered cause of action. On __________________ I served a subpoena, of which this is a true and correct copy, on [name of witness] by person­ally handing the subpoena to the named individual or in accordance with rule 176.5(a) of the Texas Rules of Civil Procedure. I also tendered to the witness the witness fees required by law at the time the subpoena was delivered.

Date: ___________________________________.

   
(Signature of person serving subpoena)