Release For Deceased Patient Affidavit Form printable pdf download

Affidavit

THIS INSTRUMENT HEREBY ACKNOWLEDGES that the undersigned,

_____________________________________________________________(“affiant”) residing at

______________________________________________________________________________

is of legal age, and does hereby swear and affirm that the following is true and accurate, to the best of his/her knowledge, under

penalty of perjury:

That I, _______________________________________________________, can state as truth that:

I am legally entitled under state law and applicable statutes to request medical records for the deceased person named

_______________________________________________________.

There is no other person or persons who have been granted or appointed as the personal representative for the above named

deceased person, whatsoever.

I am of sound mind.

I have not been coached or coerced in any way concerning this testimony and affidavit.

I certify that all the information contained in this affidavit is true, correct, and complete, and made in good faith.

I understand that knowingly making any false or fraudulent statement or representation in this matter may constitute a violation of

federal, state, or local statutes, and may result in penalties.

Signed to this ____________________ day of ______________________.

_________________________________________ _________________________________________

Signature of Affiant

Print Name of Affiant

______________________________________________________________________________

Address of Affiant

STATE OF _______________________ COUNTY OF _____________________

In ________________, on the _____________ day of ___________, 20____, before me, a

Notary Public in and for the above state and County ___________________________________,

personally appeared known to me or proved to be the person who executed the foregoing instrument, and being first duly sworn, such

person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act

and deed.

Type of ID Produced: _________________________

Affiant __ is __is not personally known to me

________________________________________________________

NOTARY PUBLIC

My Commission Expires: ________________________ (SEAL)

Release For Deceased Patient Affidavit Form