Medical Records - Frequently Asked Questions
- Is there a law that says I can see or copy my medical records?
- How can I get a copy of my medical records?
- Can a doctor charge me for copies of my medical records or x-rays?
- What if my doctor won't give me a copy of my records?
- Does a doctor have to give me a copy of reports or records he got from me or from other doctors?
- How long does a physician need to retain medical records?
- How long does a physician have to send me the copy of medical records I requested?
- What is the penalty if a physician does not respond to my request for a copy of my medical records?
- How can I correct an error in my records?
- Who owns medical records? Do the records belong to me?
- Do x-ray films belong to me?
- How do I get my medical records if my doctor moves away/retires/dies?
- How do I get my medical records transferred to my new doctor?
- Can a doctor charge to send a copy of my records to another doctor?
- How do I obtain copies of my lab results?
Is there a law that says I can see or copy my 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. The laws which authorize access to your records are available on the Internet and you might wish to review them for information about time lines a physician has to meet and the fees he or she may charge to provide the records. You can view these laws at the following Web site: http://leginfo.ca.gov/calaw.html
How can I get a copy of my medical records?
Click here for this information.
Can a doctor charge me for copies of my medical records or x-rays?
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.
What if my doctor won't give me a copy of my records?
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. 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.
Does a doctor have to give me a copy of reports or records he got from me or from other doctors?
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.
How long does a physician need to retain medical records?
There is no general law requiring a physician to maintain medical records for a specific period of time. However, there are situations or government health plans that require a provider/physician to maintain their records for a certain period of time. Several laws specify a three-year retention period: Welfare and Institutions Code section 14124.1 (which relates to Medi-Cal patients), Health and Safety Code section 1797.98(e) (for services reimbursed by Emergency Medical Services Fund), and Health and Safety Code section 11191 (when a physician prescribes, dispenses or administers a Schedule II controlled substance). The Knox-Keene Act requires that HMO medical records be maintained a minimum of two years to ensure that compliance with the act can be validated by the Department of Corporations. In Workers' Compensation Cases, qualified medical evaluators must maintain medical-legal reports for five years. Health and Safety Code section 123145 indicates that providers who are licensed under section 1205 as a medical clinic shall preserve the records for seven years. However, there is no general statute which relates to all other types of medical records.
How long does a physician have to send me the copy of medical records I requested?
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.
What is the penalty if a physician does not respond to my request for a copy of my medical records?
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.
How can I correct an error in my records?
The patient can write an "Addendum" to be placed in his or her 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 an adult patient "shall have the right to provide to the health care provider a written addendum with respect to any item or statement in his or her 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 his or her record. The health care provider shall attach the addendum to the patient's records and shall include that addendum whenever the health care provider makes a disclosure of the allegedly incomplete or incorrect portion of the patient's records to any third party."
Who owns medical records? Do the records belong to me?
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.
Do x-ray films belong to me?
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.
How do I get my medical records if my doctor moves away/retires/dies?
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 his/her 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?).
Additionally, you can contact the Medical Board's Consumer Information Unit at 1-800-633-2322, or on the Board's Web site's profiles at Check Your Doctor, to obtain the physician's address of record for his or her 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 his or her 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.
How do I get my medical records transferred to my new doctor?
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 insure 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.
Can a doctor charge to send a copy of my records to another doctor?
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.
How do I obtain copies of my lab results?
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. When the patient requests his/her 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. The test results cannot be released by the lab performing the test and must be released by the provider requesting the test(s).