The certificate of the custodian of the hospital records provided for in Sections 12-21-5 and Subpoena duces tecum; inspection; form; weight” class=”unlinked-ref” datatype=”S” sessionyear=”2020″ statecd=”AL” title=”12″>12-21-6 shall show the name of the parties to the case or proceeding and the name of the court to which made, by appropriate caption, and said certificate shall be in form in substance as follows, to-wit:

I, _____, hereby certify and affirm in writing that I am _____ of the _____ Hospital, a hospital organized or operated pursuant to or under the laws of Alabama, located at _____, Alabama, that I am custodian of the hospital records of said hospital and that the within copy of said hospital records are an exact, full, true and correct copy of said hospital records pertaining to _____.

I further certify that I am familiar with and know, and knew when made and charged, the reasonable value and price for the various charges made and shown in said hospital records pertaining to _________ and that said charges are in my judgment just, reasonable and proper and in keeping with those generally charged in the county and community where said hospital is located.

All of which I hereby certify and affirm on this ______ day of __________, 19__.