Model Attestation Statement

I, (full name of psychiatrist), hereby attest that the medical record entry for my patient (beneficiary name) on (date of service) accurately reflects the notations I made in my capacity as psychiatrist when I treated/diagnosed (him/her, choose one). I hereby attest that this information is true, accurate, and complete to the best of my knowledge.

(Psychiatrist's Signature)

(Date of Attestation)