Scribd
Upload
1K views1 page

Affidavit of Medical Records

This affidavit from the custodian of medical records certifies that the attached medical records were kept in the regular course of business and made at or near the time of the acts, events, conditions, or diagnoses recorded. The custodian confirms that the records are either originals or exact duplicates of originals and that nothing has been removed or altered. The custodian signs and dates the affidavit, which is then notarized.

Uploaded by

LuigiMangaya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
1K views1 page

Affidavit of Medical Records

This affidavit from the custodian of medical records certifies that the attached medical records were kept in the regular course of business and made at or near the time of the acts, events, conditions, or diagnoses recorded. The custodian confirms that the records are either originals or exact duplicates of originals and that nothing has been removed or altered. The custodian signs and dates the affidavit, which is then notarized.

Uploaded by

LuigiMangaya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

STATE OF TEXAS §

§
§
§
COUNTY OF ___________________

AFFIDAVIT OF MEDICAL RECORDS


Before me, the undersigned authority, personally appeared _____________________,
who, being duly sworn deposed as follows:

My name is _______________________________, I am of sound mind, capable of


making this affidavit, and personally acquainted with the facts herein stated:

I am the custodian of records for ____________________________________,


attached hereto are _____ pages of medical records. These said pages are kept in the regular
course of business, and it was in the regular course for an employee or representative of
_____________________________________, with knowledge of the act, event, condition, or
diagnosis, recorded to make the record or to transmit information thereof to be included in
such record; and the record was made at or near the time or reasonable soon thereafter.

The records attached hereto are originals or exact duplicates of originals and nothing
has been removed from the original files before making copies.

_______________________________________
Custodian of Records

SWORN TO AND SUBSCRIBED before me on the ___________ day of


___________________________, 20___.

____________________________________
NOTARY PUBLIC, STATE OF ________.

My Commission Expires: ______________

You might also like