Complaint: Medical Records
You can make a written request to either review or obtain a copy of your medical records pursuant to Health and Safety Code sections 123100 through 123149.5.
You can view these laws on the
California Legislative Information website.
Yes, pursuant to Health & Safety Code section 123110, a doctor can charge 25 cents per page plus a reasonable clerical fee. For diagnostic films,
such as an x-ray, MRI, CT and PET scans, you can be charged the actual cost of copying the films. This only applies if you have made a written request for a
copy of your medical records to be provided to you. Please note, the following exception: (d) (1) Notwithstanding any provision of this section, and except
as provided in Sections 123115 and 123120, a patient, former patient, or the personal representative of a patient or former patient, is entitled to a copy,
at no charge, of the relevant portion of the patient's records, upon presenting to the provider a written request, and proof that the records or supporting
forms are needed to support a claim or appeal regarding eligibility for a public benefit program. These programs shall be the Medi-Cal program, the In-Home
Supportive Services Program, the California Work Opportunity and Responsibility to Kids (CalWORKs) program, social security disability insurance benefits,
Supplemental Security Income/State Supplementary Program for the Aged, Blind and Disabled (SSI/SSP)benefits, federal veterans service-connected compensation
and nonservice connected pension disability benefits, and CalFresh.
As long as you requested your medical records in writing, to be sent directly to
you (and not to anyone else, like your new doctor), the physician is required to
send you a copy within specified time limits. If you are having difficulty getting
your records, you can file a complaint with the Medical Board. Please include a copy of your written request(s). If we can substantiate
the complaint, as the physician's licensing agency, the Board will take the appropriate
action against the physician's license for failing to provide the records within
the legal time limit.
The guidelines from the California Medical Association indicate that physicians
must provide anything that they are maintaining in the medical record for you (as
the patient), which includes records from other providers. So, for example, you
should be able to receive a copy of a specialist's consultation report from your
primary care physician, since he/she has incorporated it as a part of your medical
chart. You don't need "special permission" from the specialist nor do you need to
obtain this report only from the specialist.
Starting January 1, 2024, the Medical Practice Act
requires a physician to maintain medical records for at least seven
years after their last date of service to a patient (see Business and Professions Code section 2266).
In addition, please note that other areas of the law establish longer record retention schedules under certain situations
or conditions. For example, a ten-year retention period is required pursuant to
Welfare and Institutions Code section 14124.1
(relating to certain Medi-Cal patients).
If you made your request in writing for the records to be sent directly to you,
the physician must provide copies to you within 15 days. The physician can charge
a reasonable fee for the cost of making the copies. If the physician's office advises you that a fee will be charged for the records,
the medical records do not need to be provided until the fee is paid.
If the physician does not comply within the time frame you can file a written complaint with the Medical Board.
The beneficiary or personal representative of a deceased patient has a full right of access to the deceased
person's medical records under the same requirements that would apply to requests from the patient himself or herself.
(Health & Safety Code 123110, 123105(e).)
The Medical Board may take any action against the physician which is appropriate
for failing to provide the records within the legal time limit. This can range from
making sure that the doctor actually does provide you the copy you requested, to
a citation and fine or disciplinary action against the physician's medical license.
The patient, including minors, can write an "Addendum" to be placed in their medical file. The
original information will not be removed, but the new information, signed and dated
by the patient, will be placed in the file. Health and Safety Code section 123111
states that a patient "shall have the right to provide to the health care
provider a written addendum with respect to any item or statement in their
records that the patient believes to be incomplete or incorrect. The addendum shall
be limited to 250 words per alleged incomplete or incorrect item in the patient's
record and shall clearly indicate in writing that the patient wishes the addendum
to be made a part of their record. The health care provider shall attach the
addendum to the patient's records and shall include that addendum if the health
care provider makes a disclosure of the allegedly incomplete or incorrect portion
of the patient's records to any third party."
No, they do not belong to the patient. Medical records are the property of the medical
provider (or facility) that prepares them. This includes films and tracings from
diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound, etc. The
patient has a right to view the originals, and to obtain copies under Health and
Safety Code sections 123100 - 123149.5.
No, just like any other medical records, diagnostic films and tracings belong to
the physician's office or facility where they were made. The fees you paid for the
x-rays or other diagnostic imaging were for the expertise, equipment, and supplies
to take the images and diagnose them. You have a right to obtain copies of your
films if you make a written request that they be provided directly to you and not
to anyone else. The physician can charge you the actual cost of making the copies
of the films.
There is no central "repository" for medical records. If a physician moves, retires,
or passes away, sometimes another physician will either "buy out" or take over their
practice. The "active" patients are usually notified by mail (as a courtesy), and
told where to obtain their records. If you cannot locate the physician, you may
want to contact your local county medical society to see if they have any information
about the physician's practice (e.g., did someone else take over the practice?). You may click here
to find your local medical society.
Additionally, you can contact the Medical Board's Consumer Information Unit at 1-800-633-2322,
or on the Board's website's profiles at
Check
Your Doctor
, to obtain the physician's address of record for their
license. Write to the doctor at that address, even if the doctor has died, and request
that a copy of your records be sent to you. If the address has a forwarding order
on it, your letter will be forwarded to the doctor's new address. The doctor has
15 days from the time your letter is received to send you a copy of your records,
if the records are still available.
If the doctor died and did not transfer the practice to someone else, you might
have to check your local Probate Court to see whether the doctor has an executor
for their estate. You could then contact the executor to see if you can get
a copy of the records. Depending on how much time has passed, whoever is appointed
as the custodian of records can have the records destroyed.
Transferring records between providers is considered a "professional courtesy" and
is not covered by law. Most physicians do not charge a fee for transferring records,
but the law does not govern this practice so there is nothing to preclude them from
charging a copying fee. There is also no time limit on transferring records. You
might wish to contact your local medical society to see if it has developed any
guidelines on medical record transfer issues.
If you want to ensure that your new doctor receives a copy of your medical records
from your previous doctor, you can write your previous doctor requesting that a
copy of your medical records be sent directly to you. When you receive your records,
you can provide a copy of those records to any provider you choose. If you select
this method, the doctor must provide the records within 15 days of receipt of your
request.
Most physicians do not charge a fee for transferring records, but the law does not
govern this practice so there is nothing to preclude them from charging a copying
or transfer fee. There is also no time limit for record transfers, or no penalty
for failure to transfer the records, since this is a professional courtesy. You
might wish to contact your local medical society to see if it has developed any
guidelines on record transfer issues.
Health and Safety Code section 123148 requires the health care professional who
requested the test be performed to provide a copy of the results to the patient,
if requested either orally or in writing, except the results may be disclosed in
electronic form if requested by the patient and if deemed most appropriate by the health care
professional who requested the test. When the patient requests their lab
results, the health care provider should provide the results to the patient within
a "reasonable" time period after the results are received by the provider. Depending
on the results of the tests, some physicians may want the patient to schedule an
appointment to review and discuss the results and any follow-up testing or treatment
that might be required.
