01 06 AFFIDAVIT: CUSTODIAN (HOSPITAL RECORDS ACT)

• Jurisdiction: Arkansas
• Library: Arkansas Form Book - Complete (2023 Ed.)

01-06 AFFIDAVIT: CUSTODIAN (HOSPITAL RECORDS ACT)

AFFIDAVIT

Before me, the undersigned authority, personally appeared [name of custodian], who, being by me duly sworn, stated as follows:

My name is [name of custodian], I am of sound mind, capable of making this Affidavit, and personally acquainted with the facts herein stated:

1. I am the Custodian of the Records of/for [name of medical provider].
2. I am the duly authorized Custodian of the Records and have authority to certify the records.
3. The

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