Medical Expenses Affidavit Form
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1Instructions: An affidavit concerning medical expenses is sufficient if it follows this form.
Tex. Civ. Prac. & Rem. Code §18.001; Tex. Rules of Evidence Rule 902.
NO. ______________
______________________________
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IN THE JUSTICE COURT OF
______________________________
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HARRIS COUNTY, TEXAS
PLAINTIFF(S)
§
PRECINCT ___ PLACE ___
VS.
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_________________________
______________________________
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_________________________
______________________________
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_________________________
DEFENDANT(S)
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MEDICAL EXPENSES AFFIDAVIT
STATE OF TEXAS
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COUNTY OF ___________
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Before me, the undersigned authority, personally appeared _____________________________________________,
who, being by me duly sworn, deposed as follows:
My name is ______________________________________________________. I am of sound mind and capable of
making this affidavit, and personally acquainted with the facts herein stated.
I am a custodian of records for ____________________________________________________________________.
Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service
provided by ________________________________________ to ________________________________________
on _____________________. The attached records are a part of this affidavit.
The attached records are kept by ___________________________________________________________________
in the regular course of business, and it was the regular course of business for an employee or representative of
__________________________________________________, with knowledge of the service provided, to make the
record or to transmit information to be included in the record. The records were made in the regular course of
business at or near the time or reasonably soon after the time the service was provided. The records are the original
or a duplicate of the original.
The services provided were necessary and the amount charged for the services was reasonable at the time and place
that the services were provided.
The total amount paid for the services was $____________________ and the amount currently unpaid but which
_____________________________________________ __________ has a right to be paid after any adjustments or
credits is $___________________.
Signed on ____________________.
__________________________________________________
Affiant
SWORN TO AND SUBSCRIBED before me on ________________________.
__________________________________________________
NOTARY PUBLIC, State of Texas
Printed Name:
My Commission Expires:
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