Texas Business Records Affidavit printable pdf download

Texas Business Records Affidavit

BUSINESS RECORDS AFFIDAVIT

THE STATE OF TEXAS

COUNTY OF ______________

I, ______________________________________________________________, Custodian of Records for

(Custodian of Records Printed Name)

_____________________________________________, ______________________________________,

(

Provider or Facility Printed Name)

(Provider or Facility Printed Address)

____________________________________________

Texas, do hereby certify that I am of sound mind,

(Provider or Facility Printed City)

capable of making this affidavit, and personally acquainted with the facts stated herein.

Attached hereto are _____________________ pages of records from the above listed provider or facility.

The said pages were kept by the above listed provider or facility in the regular course of business, and it

was the regular course of business for me and any employee or representative of the above listed provider

or facility with knowledge of the act, event, condition, opinion, 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 reasonably soon thereafter.

The record attached hereto is the original or exact duplicate of the original and no other documents exist

on the file for ________________________________________________________________________,

(Printed Patient Name)

Medicaid recipient # :_______________ for the time period ___________________________________.

(PCN)

(Admission and Discharge Date)

___________________________________________

(Affiant’s Signature)

SWORN TO AND SUBSCRIBED before me on this the _______ day of _________________, 20____.

_________________________________________________

(Notary Public, State of Texas)

SEAL

_________________________________________________

(Notary’s printed name)

________________________________

My commission expires:

Texas Business Records Affidavit