DECLARATION OF CUSTODIAN OF RECORDS
Records of: DOB: SSN/other ID #:
Business name: Address:
I am the authorized Custodian of Records for the above business and having authority to certify the
records, declare:
A. CERTIFICATION OF RECORDS COPIED:
The following records, documents and other items in my custody have been photocopied at the above
location, in my presence and under my direction and control:
To the best of my knowledge, these records, documents and other items were prepared or compiled by
the personnel of the above-named business, in the ordinary course of business, at or near the time of the
acts, conditions or events recorded.
No records, documents, or other items have been withheld in order to avoid their being photocopied.
The following records were omitted from copying or could not be produced at this time because:
Records/Items
Reasons
B. CERTIFICATION OF NO RECORDS:
A thorough search of our files revealed none of the records, documents or other items requested exist
for the following reason:
9 Patient never treated at this facility
9 Patient is in possession of records
9 Records were lost/misplaced
9 Records purged/nothing found
9 Storage facilities were searched and no records found
9 Records were destroyed after: 9 3 9 5 9 7 9 10 years
9 Records were destroyed due to: 9 theft 9 fire 9 water
9 Radiology films: 9 misplaced/lost 9 destroyed 9 non-existent 9 not at this location
9 Billing: 9 misplaced/lost 9 not kept because this is a pre-paid health plan
9 It is possible that records exist under another name or spelling, or under another identifying number;
however, based upon the information provided, and to the best of my knowledge and belief, no such
records exist.
9 Other - explain:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct.
Executed on
at , California.
Print name:
Signature:
