Sec. 18.002. FORM OF AFFIDAVIT. (a) An affidavit concerning cost and necessity of services by the person who provided the service is sufficient if it follows the following form:
No. ___________________
AFFIDAVIT
Before me, the undersigned authority, personally appeared __________(NAME OF AFFIANT)__________, who, being by me duly sworn, deposed as follows:
My name is __________(NAME OF AFFIANT)__________. I am of sound mind and capable of making this affidavit.
On __________(DATE)__________, I provided a service to __________(NAME OF PERSON WHO RECEIVED SERVICE)__________. An itemized statement of the service and the charge for the service is attached to this affidavit and is a part of this affidavit.
The service I provided was necessary and the amount that I charged for the service was reasonable at the time and place that the service was provided.
________________________________
Affiant
SWORN TO AND SUBSCRIBED before me on the __________ day of __________, 19___.
My commission expires:
______________________
________________________________
Notary Public, State of Texas
Notary's printed name:
________________________________
(b) An affidavit concerning cost and necessity of services by the person who is in charge of records showing the service provided and the charge made is sufficient if it follows the following form:
No. ___________________
AFFIDAVIT
Before me, the undersigned authority, personally appeared ______(NAME OF AFFIANT)______, who, being by me duly sworn, deposed as follows:
My name is __________(NAME OF AFFIANT)__________. I am of sound mind and capable of making this affidavit.
I am the person in charge of records of __________(PERSON WHO PROVIDED THE SERVICE)__________. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that __________(PERSON WHO PROVIDED THE SERVICE)__________ provided to __________ (PERSON WHO RECEIVED THE SERVICE)__________ on __________(DATE)__________. The attached records are a part of this affidavit.
The attached records are kept by me in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by __________(PERSON WHO PROVIDED THE SERVICE)__________ or an employee or representative of __________(PERSON WHO PROVIDED THE SERVICE)__________ who had personal knowledge of the information. The records were made at or near the time or reasonably soon after the time that the service was provided. The records are the original or an exact duplicate of the original.
The service provided was necessary and the amount charged for the service was reasonable at the time and place that the service was provided.
________________________________
Affiant
SWORN TO AND SUBSCRIBED before me on the __________ day of __________, 19___.
My commission expires:
______________________
________________________________
Notary Public, State of Texas
Notary's printed name:
________________________________
(b-1) Notwithstanding Subsection (b), an affidavit concerning proof of medical expenses is sufficient if it substantially complies with the following form:
Affidavit of Records Custodian of
____________________________________________
STATE OF TEXAS §
§
COUNTY OF _____________________§
Before me, the undersigned authority, personally appeared __________, who, being by me duly sworn, deposed as follows:
My name is ___________________________________. I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated.
I am a custodian of records for __________. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that __________ provided to __________ on _____. The attached records are a part of this affidavit.
The attached records are kept by __________ in the regular course of business, and it was the regular course of business of __________ for an employee or representative of __________, with knowledge of the service provided, to make the record or to transmit information to be included in the record. The records were made in the regular course of business at or near the time or reasonably soon after the time the service was provided. The records are the original or a duplicate of the original.
The services provided were necessary and the amount charged for the services was reasonable at the time and place that the services were provided.
The total amount paid for the services was $_____ and the amount currently unpaid but which __________ has a right to be paid after any adjustments or credits is $_____.
________________________________
Affiant
SWORN TO AND SUBSCRIBED before me on the __________ day of _____, _____.
________________________________
Notary Public, State of Texas
Notary's printed name:___________
My commission expires:___________
(b-2) If a medical bill or other itemized statement attached to an affidavit under Subsection (b-1) reflects a charge that is not recoverable, the reference to that charge is not admissible.
(c) The form of an affidavit provided by this section is not exclusive and an affidavit that substantially complies with Section 18.001 is sufficient.
Added by Acts 1993, 73rd Leg., ch. 248, Sec. 1, eff. Aug. 30, 1993.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 560 (S.B. 679), Sec. 2, eff. September 1, 2013.