Here is the text I have always used and gotten all of the information I needed. Some have been gratis; some I have been charged for. Copying in the paper documents usually runs about $1 per page, however I got the biggest one that was 75 pages for $20 when I balked at the price and delayed picking them up. The flustered head of records finally called one day and said she would reduce the amount simply because she wanted them off her desk. I was happy to oblige as that was a more appropriate amount IMO. The X-rays were $5 per copy and for an upper GI alone there were 19 X-rays. Very pricey, but there is a difference between making a zerox copy and actually duplicating negatives. My .10 and I think I got my money's worth. ========================================= I authorize <Name of Dr, Clinic, etc> to release the medical records of <Your Name>, birth date <m/d/y>, SSN <123-45-6789> from <m/d/y of first time you visited for this problem> through <today's date> including (but not limited to) doctors reports, surgeons reports (<m/d/y of each incidence>), results of all tests and procedures performed, X-Rays, photos, video and audio reports.
These records are for Dr. Xyz Mailing Address Fax #
My appointment is <Day m/d/y - I put the day in because oftimes I have to pick them up a day or two after I take this in> at H:MMam so I will need to pick these up by closing time <Day m/d/y>. If there is a problem providing these records please let me know as soon as possible. ================================= I try to pick up the records myself and then while I'm still in the building I go through them page by page to make sure none of the important records are missing. The first three times I did this they had 'accidentally' omitted the surgical reports and biopsy reports from my TAH and the exploratory lap that was done before it. That no longer happens.
Hope this helps Marla