Fill and Sign the Name and Address of Assignee Form

AFFIDAVIT OF CUSTODIAN OF MEDICAL RECORDS STATE OF _____________________ COUNTY OF __________________ I, _________________________________________, am the duly authorized custodian of the medical records of _________________________________________________, and as such have the authority to certify that medical records attached hereto constitute a true and correct copy of the medical records pertaining to the treatment of ________________________________ at your office or institution from the _____ day of ___________, 20___, to the _____ day of ___________, 20___. The attached records were prepared by the personnel of _________________________________________________, staff physicians, or persons acting under the control of either, in the ordinary course of business, at or near the time of treatment reported therein. The reasonable charges incurred by ________________________ in furnishing the copy of these records is $_____________. ________________________________CUSTODIAN SWORN TO AND SUBSCRIBED BEFORE ME, this the ____ day of _________, 20____. _________________________________________ NOTARY PUBLIC (SEAL) My Commission Expires;____________________________
(if applicable) witness (1) ...................................................................................................................................... (2) ...................................................................................................................................... (3) name ..................................................................................................................................... (4) date of birth (5) date of ............................................................................................................ (6) date this ............................................................................................................(7) date of death (8) name ..................................................................................................................................... (9) ....................................................................................................................................... (10) ...................................................................................................................................... (11) address ..................................................................................................................................... (12) ............................................................................................................................................. (13) name ..................................................................................................................................... .............................................................. (14) address ..................................................................................................................................... .............................................................. (15) date .......................................................................................................................................... ............................................................. (16) signature ..................................................................................................................................... ............................................................. (17) signature ..................................................................................................................................... ............................................................. (18) (if applicable) custodian's signature ..................................................................................................... ............................................................. (19) signature ..................................................................................................................................... ............................................................. (20) form ..................................................................................................................................... 2. I, , do solemnly swear (or affirm) that the above affidavit is true. ........................................................................................................... 1. The foregoing is an example of a verified form for application to court for medical examination of a person. An additional form is a form for a petition for medical examination. A petition for medical examination must contain the following information, and can be submitted in or issued in any form: a description, a description of the person being examined, the name, address, and telephone number of the person to be examined under oath. The name, address, location of the office, and the period of time in which the examination should be done. A description of the conditions or symptoms that the person is suffering from. The diagnosis of the physical or mental condition. The type of examination to be performed. (see appendix for additional information concerning the application to court under these sections. B. Form(s) and application for court medical examination 1. On receipt of an application for a court medical examination, the court shall enter a decision upon it not later than one. or two days after it is served. 2. Thereafter, if notice of any hearing, hearing before a magistrate, to which a respondent may be called, is properly filed, the respondent may be heard at any time within thirty days after the application for the hearing has been served. 3. If notice of an adjournment or delay is properly filed, the court shall enter a decision upon it not later than one.