Medical Records Affidavit

BEFORE THE MISSISSIPPI WORKERS COMPENSATION COMMISSION MWCC NO. ___________________ ______________________________ CLAIMANTVS. ______________________________ EMPLOYERAND ______________________________ CARRIER MEDICAL RECORDS AFFIDAVIT STATE OF _________________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for said jurisdiction,_____________________, M.D. (or, alternatively, ______________________, medical records custodian), who, upon his/her oath, stated that the attached records ar e a true and correct copy ofthe medical records relating to the examination, evaluation, and/or trea tment of the above-namedclaimant as generated in the regular course of the medical practice of _ _________________,M.D. __________________________________ Name of Affiant __.___SWORN to and subscribed before me, this the _______ day of _____________ _, __________________________________ Notary Public My commission expires: ___________________ Physicians name Specialty of practice Address Telephone number This affidavit was prepared by: Attorneys name Mississippi Bar identification number Address Telephone number MWCC Form - Medical Records Affidavit (1993) (File original only)