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AFFIDAVIT CONCERNING COST AND NECESSITY OF SERVICES
[Texas Civil Practices & Remedies Code, 18.01 and 18.02]
[To be signed by records custodian of entity that provided the service]

Before me, the undersigned authority, personally appeared ________________________ (referred to herein as "Affiant"), who, being by me duly sworn, deposed as follows:

1. Affiant is a person in charge of the records of _____________________________ _______________________________ (referred to herein as "Service Provider"), copies of which are attached to this affidavit (referred to herein as the attached records").. I am of sound mind and capable of making this affidavit.

2. On the dates shown in the attached records _____________________________ Service Provider provided services described therein to ________________________________ (referred to herein as "Consumer"). The attached records, which consist of an itemized statement of the services and the charges for the services, are made a part of this affidavit. The services provided by Service Provider were necessary and the amounts that the Service Provider charged for the services were reasonable at the time and place that the services were provided.

_____________________________
___________________ [Affiant]


SWORN TO AND SUBSCRIBED before me on the ____ day of __________, 20____, by _____________________.


___________________________________
NOTARY PUBLIC, STATE OF TEXAS

NOTE: Where appropriate, the actual names or terms such as "Medical Services Provider" and "Patient" should be substituted for "Service Provider" and "Customer."

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NOTE:This form and related information is an aid for attorneys only to be used in conjunction with their own independent research and analysis, and is not to be interpreted as creating an attorney-client relationship with any person or giving legal advice to the public.

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