Affidavit Of Medical Records - Photostat printable pdf download

Affidavit Of Medical Records - Photostat

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

AND

SUBSCRIBED

before

the

___________

day

___________________________, 20___.

____________________________________

NOTARY PUBLIC, STATE OF ________.

My Commission Expires: ______________

Affidavit Of Medical Records - Photostat