Effective March 1, 2010, the Texas Supreme Court changed the requirements regarding Rule 902 self-authenticating medical expense affidavits. The following is an example of an affidavit that should meet the requirements of the new Rule 902(10)(c):
AFFIDAVIT OF CUSTODIAN OF MEDICAL/BILLING RECORDS
HEALTHCARE PROVIDER: ____________________
BEFORE ME, the undersigned authority, personally appeared ____________________________ (NAME OF AFFIANT), who, being by me duly sworn, deposed as follows:
My name is __________________________ (NAME OF AFFIANT). I am of sound mind and capable of making this affidavit.
I am the person in charge of records of the above referenced health care provider. Attached to this affidavit are records that provide an itemized statement of the service and/or the charge for the service that the above referenced health care provider provided to patient from [KEYBOARD DOA] to _______________ (DATE). The attached records are a part of this affidavit.
I have checked or circled the type of records being included with this affidavit:
__________Medical Records __________Billing Records
The attached records are kept by me in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by the above referenced health care provider or an employee or representative of the above referenced health care provider who had personal knowledge of the information. The records were made at or near the time or reasonably soon after the time that the service was provided. The records are the original or an exact duplicate of the original.
FOR BILLING RECORDS:
The total amount of the charges is: $__________________________
The amount adjusted or written off is: $__________________________
The total amount paid for the services is: $__________________________
The amount currently unpaid for which the Healthcare
Provider has a right to be paid after any adjustments or
credits is: $__________________________
SWORN TO AND SUBSCRIBED before me on the _____ day of_________________, 20____.
NOTARY PUBLIC, STATE OF TEXAS
Printed Name of Notary Public:
My Comm. Exp. ______________________
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