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