Copying Medical Records (when not Medically necessary), Sum of:

Copying – $35 (first 20 pages) + $0.30 per page extra
Out of pocket disbursements – At cost
Physician review of records – $500 / hour

Uninsured Reports / Forms

School / Camp Notes – $20
Work Notes – $20
Sick Notes – $20

Accident Benefits Schedule Claim Form

OCF-3 = Disability Certificate – $140
OCF-18 = Treatment Plan – $140
OCF-19 = Catastrophic Impairment – $140
OCF-23 = Treatment Confirmation – $140

Health Insurance Reports

Attending Physician Statement – $140
Disease Specific Questionnaire – $100
System Specific Examination – $100
Insurance Medical Examination – $200