Simply replace the unfilled areas such as "" and "[date]" with your information.
Dear [attorney's name],
Enclosed please find the medical records you requested regarding [Patient]. Also enclosed is a certification that these are the true, correct, and completed medical records kept by this office for [Patient]. There are no other records in our possession.
As we previously notified you, the fee for copying these records is [fee per page] per page. We request that you promptly remit payment of [total due for copies] to our office for these copies. The medical records packet attached includes [number of pages] pages.
Thank you for your prompt payment of this fee. Failure to pay this fee will result in delayed processing of future record requests from your office.