Public Health Law Map - Beta 5 - Medical and Public Health Law Site

is the custodian of records for Dr. Mary Jones:
Sample Affidavit
1. State your full name, residence, and occupation.
2. Has John Doe been treated or examined by Dr. Mary Jones?
PROOF OF RECORDS
1. Has Dr. Jones made or caused to be made any notes, records, and/or reports of
the examination and/or treatment of said patient?
2. Were the entries on these notes, records, and/or reports made at the time, or
shortly after the time, of the transaction recorded by these entries?
3. Were these notes, records, and/or reports made or caused to be made by Dr.
Jones in the regular course of business as a doctor or physician?
4. In the regular course of business at Dr. Jones’s facility, did each of the persons
who signed the reports contained in the record either have personal knowledge of
the entries shown on the report or obtain information to make the entry from
sources who had such personal knowledge?
5. Do you have such records as described above on John Doe?
6. Were these records kept as described above?
7. Please hand such records on John Doe to the notary public taking this deposition
for photocopying and marking as exhibits to be attached to this deposition.
8. Have you done as requested in the preceding question? If not, why not?
PROOF OF CHARGES
1. Are you familiar with the charges usually and customarily made for the medical
services reflected in the bills furnished as a part of the requested written records?
2. Please state the full amount of charges in the treatment of John Doe.
3. Please state whether such charges are reasonable and customary for like or
similar services rendered in the vicinity in which they were incurred.
4. Were the services performed, as reflected in the records, necessary for the proper
treatment of the patient in question?
d) Oral Depositions
A party may take the oral deposition of any person who has information relevant to
the litigation. The person to be deposed may agree to appear at a certain time and
place for the deposition, or the deposing party may ask the court to order the
witness to appear. All of the parties to the litigation must be notified of the time and
147