Free Medical Records Affidavit - Mississippi

BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMMISSION

MWCC NO. ___________________ ______________________________ VS. ______________________________ AND ______________________________ 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 are a true and correct copy of the medical records relating to the examination, evaluation, and/or treatment of the above-named claimant 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: ___________________ Physician's name Specialty of practice Address Telephone number This affidavit was prepared by: Attorney's name Mississippi Bar identification number Address Telephone number MWCC Form - Medical Records Affidavit (1993) (File original only) CARRIER EMPLOYER CLAIMANT