Custodian of Records Affidavit - Michigan

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Michigan · Fillable PDF · Free

Hospitals, clinics, and businesses use this sworn affidavit when producing records for an insurance claim or lawsuit, to confirm the copies are true, complete, and kept in the regular course of business. Hospitals, clinics, and businesses use this sworn affidavit when producing records for an insurance claim or lawsuit, to confirm the copies are true, complete, and kept in the regular course of business.

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Who this form is for

• Hospitals, clinics, and businesses use this sworn affidavit when producing records for an insurance claim or lawsuit, to confirm the copies are true, complete, and kept in the regular course of business.

What you'll need

• Read the packet and check the receiving agency's required form.
• Gather the names, dates and supporting records requested in the document.
• Review the packet's signing, identification and witness instructions.

How to complete it

1. Fill in the request (Page 1) Identify the records, dates, and number of pages produced, or check that no records were found.
2. Swear before a notary Sign under oath before the notary with a current, government-issued photo ID.
3. Attach the affidavit to the records it describes.

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