CAUSE NO.

COST AND NECESSITY OF SERVICES

BILLING RECORDS AFFIDAVIT

(Pursuant to Tex. Civ. Prac. & Rem. Code §§ 18.001 & 18.002 &
Haygood v. de Escabedo, 54 Tex. Sup. J. 1377(2011))

RECORDS PERTAINING TO:

Before me, the undersigned authority, personally appeared:

AFFIANT (Name of Custodian of Records)
who by me being duly sworn, deposed as follows:

I, the undersigned, am over 18 years of age, of sound mind, capable of making this affidavit, and
personally acquainted with the facts herein stated:

I am the CUSTODIAN OF RECORDS FOR: .

Attached hereto are copies of records kept in the regular course of business, at the office of the above, and
it was in the regular course of business, at the office of the above, for an employee, or representative, with
personal knowledge of the act, event or condition, opinion, or diagnosis recorded to make the
memorandum or record or to transmit information hereof to be included in such memorandum or record.
The memorandum or record was made at or near the time of the act, event or condition recorded or
reasonably soon thereafter. Attached to this affidavit are pages of billing records from
dates of service to .

Attached to this affidavit and incorporated by reference are all records of service and
correspondence including an itemized statement of the services and care rendered to the above
patient and the charges for same. All of the items were necessary to provide good care for the
above patient.

The service provided was necessary and the amount charged for the service was reasonable at the
time and place that the service was provided. For the service provided, the amount paid for services
$ , and the amount currently unpaid but still outstanding is $ , add up
to a total of $ , which is the amount this facility has a legal right to recover.

AFFIANT (Name of Custodian of Records)

SUBSCRIBED AND SWORN TO BEFORE ME this the day of , 20 .

Notary Public
In and for the State of
My Commission Expires: