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Records custodian affidavit florida

Affidavit custodian 2026

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The document is an affidavit from a custodian of medical records, certifying that the attached medical records are accurate copies related to a specific individual's treatment during a defined period. It includes details about the custodian's authority, the preparation of the records, and any associated charges for providing these copies.

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Click ‘Get Form’ to open the affidavit custodian in the editor.
Begin by filling in the 'STATE OF' and 'COUNTY OF' fields with the appropriate jurisdiction details.
In the first blank line, enter your name as the authorized custodian of medical records.
Next, specify the name of the individual whose medical records you are certifying.
Fill in the date range for which the medical records pertain, using the provided blanks for start and end dates.
Indicate the name of the institution or office where treatment occurred in the designated field.
Lastly, enter any reasonable charges incurred for providing these records in the specified area.
Sign your name as 'CUSTODIAN' at the bottom of the form and ensure to have it notarized by a public notary.

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affidavit of custodian of records form

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