Medical Records Affidavit

Records Pertaining To:

Before me, the undersigned authority, personally appeared ,

who being by me duly sworn, deposed as follows:

My name is_________________________. I am over eighteen (18) years of age and competent

to make this affidavit. The facts stated in this affidavit are within my personal knowledge and are true
and correct. I am the custodian of the medical records for ______________________________.
Attached to this affidavit are _______pages of medical records from dates of service
__________________________ to __________________________.

These pages of medical records are kept by _______________________________ in the regular

course of business of _________________________________for an employee or representative
of _______________________________________, with knowledge of the act, event, condition,
opinion, or diagnosis records, to make the records or to transmit information thereof to be included
in the record. To the best of my knowledge, the record was made at or near the time or reasonably
soon thereafter. The records attached to this affidavit are the exact duplicates of the available
original.

AFFIANT (Custodian of Records)

Sworn to and subscribed before me on the day of , 20__.

________________________________
NOTARY PUBLIC
In and for the State of
My Commission Expires: