Form- Affidavit When Patient Isn't Included On Police Report

Dear Provider;

Please see the attached Affidavit regarding non-inclusion in a police report. It is to be used when a patient is treating at your office and was not included on the police report.

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

This form should be used to “CYA” in the event the insurance company claims the patient was not involved in the motor-vehicle accident because the patient was not listed on the police report. It should not be sent to the insurance company unless they deny your bills.

Because patient’s can be hard to reach after they stop treating it is best to get the patient to complete this affidavit while they are still treating. Also, please make sure they get this form notarized.


Abraham S. Ovadia, Esq.


COUNTY OF ___________________


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.
  1. I was involved in a motor vehicle collision on or about _____________________.
  1. I was not included in the police report; however, I was inside the motor vehicle at the time of the motor vehicle collision.
  1. I do not know why the police officer failed to list me as a passenger in the police report.
  1. The following people were also inside the motor vehicle at the time of collision:







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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