Affidavit for Proof of Mailing

Please see the attached Proof of Mailing Affidavit. It is to be used when an insurance company claims that the bills were never received and when your office doesn’t have a “certified mail card.”

Click here to see a nice PDF that you can download for free

This form should only be completed when the insurance company claims they did not receive the bills. It should not be sent to the insurance company unless litigation becomes necessary.

Please make sure this form gets notarized.


Abraham S. Ovadia, Esq.


COUNTY OF ___________________


(Regular Course of Business)

After being duly sworn, I state upon personal knowledge that:

  1. I am ________________________; I am over the age of 18; and I am legally competent.

2. I have personal knowledge relative to the claim for services rendered by Plaintiff to patient ______________________, (“Patient”) and have reviewed my entire medical file for this patient.

3. I am the person responsible for mailing bills to insurance companies.

4. It is a regularly conducted business practice for me to mail bills out on:




5. On _______________________________, I submitted bills to ____________________________________________ (“Insurance Company”) in the ordinary and regular course of business.

Further Affiant Sayeth Naught.


Patient Signature


Print Patient Name

Sworn to before me, a Notary Public of this State, by __________________________, who is/not personally known to me and presented ___________________________ as identification this _____ Day of _____________________, 20___.


Notary Public


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