Google is your friend in this situation. Google medical office financial policies, and you will see many examples. You can also go onto the websites of various doctor's offices in your area/any area in the country, and look at the ones they have uploaded in the section for patient forms.
Some words of advice...if you are going to charge patients for copying their medical records if they ask for their records, make sure to say that the records are the property of the practice, and that the patient will be charged the applicable fees as set by state mandate/law, and then ONLY charge what your state allows for this. Each state has different fees. Some offices think they can charge whatever they want for this, and they can't. Additionally, if you are going to charge a collection fee if someone has to go to collections, this is also has to be within state guidelines.