Rights and Responsibilities Regarding Medical Records in California, Part I

Under California law patients have a guaranteed right to access to their medical records. This is made clear by the plain language of Health & Safety Code § 1231001, which reads, in relevant part, as follows: The Legislature finds and declares that every person having ultimate responsibility for decisions respecting his or her own health care also possesses a concomitant right of access to complete information respecting his or her condition and care provided. However, this simple and straightforward declaration does not convey the myriad issues that exist in the real world when it comes to access to medical records – issues such as privacy concerns, practicality, and urgent medical necessity. Over the next few months we will be exploring issues relating to patients’ rights and health care providers’ responsibilities regarding patients’ medical records. Today’s installment will address the procedure provided by California law for patients’ to access their own medical records.2 Let’s start by defining what constitutes a patient’s records. According to California law patient’s records are: [R]ecords in any form or medium maintained by, or in the custody or control of, a health care provider relating to the health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient. “Patient records” includes only records pertaining to the patient requesting the records or whose representative requests the records. “Patient records” does not include information given in confidence to a health care provider by a person other than another health care provider or the patient, and that material may be removed from any records prior to inspection or copying under Section 123110 or 123115. “Patient records” does not include information contained in aggregate form, such as indices, registers, or logs.3 California law gives you several different options for accessing your records, as well as giving your provider different avenues for responding to your request. If you wish to personally inspect your records, submit a written request to the health care provider. Within 5 days, the provider must make the records available within business hours for you to inspect or copy. You may be accompanied by one person of your choosing. The provider may charge you reasonable clerical fees for making the records available. Additionally, the provider may require verification of your identity.4 In order to obtain a copy of your records, again you need to submit a written request to your health care provider. In this case, the provider has 15 days after your request to respond. The provider may also charge reasonable copying fees not to exceed the following amounts: 25 cents per page; or 50 cents per page for records which are stored on microfilm.5 In lieu of providing your access to or copies of your entire medical record, your health care provider may instead provide you with a detailed summary of your record.6 This record must provided to you within 10 days of your written request. However, under certain circumstances – if your record is of extraordinary length or if you have been discharged from a healthcare facility within the last 10 days – the provider may take up to 30 days. They are still required to respond to your request within 10 days in order to notify you of the extra time required and provide you with the date the summary will be completed. At their discretion, the provider may confer with you regarding your reasons for requesting your record. If you have requested your entire record, but are really interested in only a certain health related event, the provider may provide you a summary of only that part of your record. The provider may charge you for the actual time spent preparing the summary. A detailed summary is required by Health & Safety Code § 123130(b) to contain the following:

    • Chief complaint of complaints including pertinent history;
    • Findings from consultations and referrals to other health care providers;
    • Diagnosis, where determined;
    • Treatment plan and regimen including medications prescribed;
    • Progress of the treatment;
    • Prognosis including significant continuing problems or conditions;
    • Pertinent reports of diagnostic procedures and tests and all discharge summaries;
    • Objective findings from the most recent physical examination, such as blood pressure, weight, and actual values from routine laboratory tests;
    • A list of all current medications prescribed, including dosage, and any sensitivities or allergies to medications recorded by the provider.

If you are requesting records in order support an appeal for eligibility for certain public benefits programs, the health care provider shall provide you with a copy of the relevant potion of your record[7]free of charge within 30 days of your request. If you are successful in your appeal, the provider may bill you at the rates outlined above. Additionally, if an attorney is representing you and paying your costs for your appeal, you may not receive a free copy of your record. The eligible public benefits programs are:

    • Medi-Cal;
    • Social Security Disability Insurance (SSDI); and
    • Supplemental Security Income/State Supplementary Program for the Aged, Blind, and Disabled (SSI/SSP).[8]

Well, that is it for our discussion of basic procedures for accessing your own medical records. Sounds easy, doesn’t it? Stay tuned, because next time we will discuss the exceptions to and complications with the above and your remedies if a health care provider fails to comply with your requests.

[2] These same rules and procedures apply to the parent or legal guardian of a minor patient who cannot by law consent to medical treatment.
[3] California Health & Safety Code § 123105(d)
[4] California Health & Safety Code § 123110(a)
[5] California Health & Safety Code § 123110(b)
[6] California Health & Safety Code § 123130.
[7] Defined by California Health & Safety Code § 123110(d)(1) as “those records regarding services rendered to the patient during the time period beginning with the date of the patient’s initial application for public benefits up to and including the date that a final determination is made by the public benefits program with which the patient’s application is pending.”
[8] California Health & Safety Code § 123110(d-f).