This affidavit is to be used by the custodian of medical records to certify that records obtained by the attorney regarding the client's treatment are true and correct copies.
Affidavit of Custodian of Medical Records
State:
Multi-State
Control #:
US-PI-0007
Format:
Word;
Rich Text
Instant download
Description
Definition and meaning
An Affidavit of Custodian of Medical Records is a legal document that certifies the authenticity of medical records. It is typically filled out by the individual responsible for managing these records, known as the custodian. This affidavit confirms that the attached medical records are accurate copies pertaining to a patient's treatment, prepared in the usual course of business.
How to complete a form
Completing an Affidavit of Custodian of Medical Records involves several important steps:
- Provide your full name as the custodian of the records.
- Clearly identify the patient whose medical records you are certifying.
- State the date range of the medical records included in the affidavit.
- Specify the reasonable charges for providing the copies of the medical records, if applicable.
- Sign the affidavit in the presence of a notary public.
Make sure to double-check all entered information for accuracy before submission.
Who should use this form
The Affidavit of Custodian of Medical Records should be used by individuals or organizations that maintain medical records, such as hospitals, clinics, and private practices. This form is particularly useful for:
- Healthcare providers needing to provide copies of patient records for legal or administrative purposes.
- Individuals requesting their own medical records to ensure accuracy and completeness.
- Legal representatives who require certified medical documents for cases involving personal injury or medical malpractice.
Key components of the form
When filling out the Affidavit of Custodian of Medical Records, ensure it includes the following key components:
- Custodian's Name: The full name of the person authorized to certify the records.
- Patient Information: Details regarding the patient, including their full name.
- Date Range: Specific dates during which the records were created.
- Certification Statement: A declaration that the attached records are true and accurate.
- Signature and Notarization: The signature of the custodian and a notary public seal.
Common mistakes to avoid when using this form
To ensure the validity of your Affidavit of Custodian of Medical Records, avoid the following common mistakes:
- Failing to sign the document before a notary public.
- Leaving out critical information such as the patient's name or the date range of the records.
- Not including the reasonable charges for providing copies, if applicable.
- Errors in the certification statement which could lead to disputes.
What to expect during notarization or witnessing
When you take your Affidavit of Custodian of Medical Records for notarization, be prepared for the following:
- You will need to present valid identification to verify your identity.
- The notary public will review the form for completeness and accuracy.
- Once satisfied, the notary will sign and seal the document, making it legally binding.
Key takeaways
The Affidavit of Custodian of Medical Records is an essential document that authenticates medical records as true copies. It is vital for legal situations where medical records may be necessary. Completing it accurately and ensuring proper notarization are crucial steps for its effectiveness.
How to fill out Affidavit Of Custodian Of Medical Records?
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FAQ
In addition to providing records that manage and document the patient's care, medical records are used in reimbursement, research, and legal issues. Because the medical record is a legal document, many rules and regulations apply, including regulations on documentation, record retention, privacy acts, and disclosure.
A medical chart is a complete record of a patient's key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
Medical records specialists organize and maintain health information both in paper files and in electronic systems. They check data for accuracy, assign codes for insurance reimbursement, record information and keep file folders and electronic databases up-to-date.
What are some of the examples of a custodian of the record? In a large medical office or hospital there is an actual Medical Records Department, an office manager of a medical office may be the custodian, the physician whom has his own office could be the custodian.
In order to obtain these records, an applicant must request a certified copy directly from the agency that issued or holds the original documents. Only the agency that is the custodian of the records can create a certified copy of the record. affixing his or her seal of office to the photocopy or extract.
A Medical Records Clerk is in charge of managing patient health files in a facility. Also known as Health Information Clerks, their duties include filing records, assisting in audits, and collecting information.
EHR. Electronic health record that keeps basic profile information on a patient. Patient Data. Info that is provided by patient then updated as necessary. Medical History (Hx) Physical Examination (PE) Consent Form. Informed Consent Form. Physician's Orders. Nurse's Notes.
The health information custodian is the person who has been designated responsible for the care, custody, and control of the health record for such persons or institutions that prepare and maintain records of healthcare.
In order to obtain these records, an applicant must request a certified copy directly from the agency that issued or holds the original documents. Only the agency that is the custodian of the records can create a certified copy of the record. affixing his or her seal of office to the photocopy or extract.
