Certification of Healthcare Records
Author:Attorney Dan A. RieglemanN63 W23965 Main StreetSussex, Wisconsin 53089Prepared: 06/01/10Certification Form to Accompany Requested Health Care RecordsPatient:Records From: to I, , Healthcare Records Clerk / Custodian for Dr. of FORMTEXT ????? hereby certify that the documents attached to this certificate consisting of pages constitute an accurate, legible and complete copy of the healthcare records of the patient named above for the period of time shown above. The records from which this copy was made were made in the regular course of the business of Dr. and at the time of the events recorded in the records or within a reasonable time after those events. Medical Records Clerk / CustodianSubscribed and sworn to before me on this day of , 20 .Notary Public, State of WisconsinMy commission expires: Important Notice: Please read the disclaimer when using this website. All materials provided with white papers; whether for a fee or not, are intended for general informational purposes since the services of a competent professional should be sought for any specific legal needs. Use of the website and access/use of this form does not create or constitute an attorney-client relationship with any attorney on the website or providing this resource item. ................
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