MEDICAL RECORDS CERTIFICATION - Kentucky
RECORDS CERTIFICATION
| |
|Facility/Business Name |
| |
|Facility/Business Address |
| |
|Facility/Business Phone Number |
|Patient/Customer Name: | |
|Patient’s Medical Record Number/Customer Account Number: | |
|No. of Pages: | |
|The copies of records for which this certification is made are true and complete |
|reproductions of the original or microfilmed records which are housed in |
| | |(facility/business name). The original records were made in |
|the regular course of business, and it was the regular course of |
| | |(facility/business name) to make such records at or near the |
|time of the matter recorded. This certification is given by the custodian of |
|records pursuant to KRS 422.300, KRS 422.330 and KRE 902 in lieu of his or her |
|personal appearance. |
______________________________
Records Custodian
COMMONWEALTH OF KENTUCKY )
|COUNTY OF | |) |
Subscribed and sworn to me by ______________________, this the ____ day of _______________.
My commission expires ____________________________.
______________________________
Notary Public
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