CERTIFICATION OF MEDICAL RECORDS
CERTIFICATION OF MEDICAL RECORDS
Patient Name: __________________________________________________________________
I certify that the documents attached to this certificate, consisting of ___________ pages, are accurate and complete duplicates of the original medical records of the patient listed above for the following period of time:
_____________________________________ to ______________________________________
Exclusions:
None
As follows: __________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Certification of No Records: A thorough search of our files, carried out under my direction, revealed no documents, records or other materials called for in the medical records request.
I further certify that the produced records are a true copy of ALL the records requested and are kept in the course of regularly conducted activity.
Executed on this _________ day of _______________________, _________
______________________________________________________________ Records Custodian (signature)
________________________________________________________________ Printed Name of Records Custodian
_______________________________________________________________ Name of Facility or Practice (Please Print)
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