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Doj custodian of records

Custodian of record 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 specified time 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 custodian of record document in the editor.
Begin by entering your name in the designated field, confirming your role as the authorized custodian of medical records.
Fill in the name of the individual whose medical records you are certifying, ensuring accuracy for legal compliance.
Specify the date range during which the treatment occurred by filling in both start and end dates clearly.
Indicate the name of the institution or office where treatment was provided, ensuring it matches official records.
Complete any additional fields regarding charges for providing copies of records, if applicable.
Sign and date the form as the custodian, then prepare it for notarization by a public notary.

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