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Patient Access to Health Records


By: Patient Advocacy Program-University of San Diego

This page has been prepared to answer questions you may have about access to your health records. The California legislature has enacted laws whereby people can gain access to ther health records or summaries of the their records. The laws are contained in §123100 through §123149 of the Health and Safety Code.

If you have any further questions or need further assistance, please contact:

Patient Advocacy Program
University of San Diego
School of Law
5998 Alcalá Park – UP304
San Diego, CA 92110-2492
(619) 543-9998

or

1-800-479-2233

DEFINITIONS

A Health Care Provider is a licensed health care facility or clinic. This includes inpatient and outpatient services of psychiatric hospitals, psychiatric units in general hospitals, and home health agencies.

A Health Care Provider is also defined as any licensed physician, psychiatrist, psychologist, licensed clinical social worker or licensed marriage, family, and child counselor.

Mental Health Records are patient records, in whole or part, relating to evaluation or treatment of a mental disorder or alcohol and/or drug abuse.

Patient Records are records in the possession or control of a health care provider relating to the health diagnosis, or condition of a patient, or relating to treatment provided to the patient. This does not include information given in confidence to a health care provider by a non-health care provider other than the patient.

A Patient is a person currently receiving or who previously received the services of a health care provider.

A Patient’s Representative is a parent or guardian of a minor who is or was a patient, or the guardian or conservator of an adult patient.

INSPECTION AND COPYING OF RECORDS

Section 123110 of the California Health and Safety Code gives patients the right to inspect their records and obtain copies by making a written request to whoever has the records.

A patient must be willing to pay reasonable costs in locating and making the records available.

The health care provider has five working days from receiving a request to make records available for inspection their office or facility.

The health care provider can require the requesting party to show identification before allowing inspection of records.

To have records mailed, a request must be made in writing specifying the records to be copied and sent.

The person requesting must pay a fee to defray the cost of copying. The fee cannot exceed $0.25 per page or $0.50 per page for records on microfilm, plus reasonable clerical costs. The health care provider has fifteen (15) days from receiving the request to send the records.

Section 123130 of the Health and Safety Code allows a health care provider to prepare a summary of the record for inspection and copying. The summary shall be available within ten (10) working days from the date of the request. If the record is lengthy or the patient was discharged from a licensed health facility within the last ten (10) days, the health care provider has up to thirty (30) days to deliver the summary and shall notify the patient of the date that the summary will be completed.

If the health care provider decides to prepare a summary, a reasonable fee, based on the actual time spent preparing the summary, may be charged.

A health care provider may confer with the patient in an attempt to clarify the patient’s purpose and goal in obtaining his or her record. The health care provider may then provide a summary relating only to the specific information requested. A summary shall include:

  • Chief complaint(s), including history;
  • Findings from consultations and referrals to other care provider;
  • Diagnosis, where determined;
  • Treatment plan, progress of treatment and medications prescribed, including dosage and any sensitivities or allergies;
  • Reports of diagnostic procedures and tests and all discharge summaries;
  • Results of the physical examination and routine laboratory tests; and
  • Prognosis including significant, continuing problems or conditions.

DENIAL OF RIGHT TO INSPECT OR COPY

Access to records can be denied if the health care provider determines that it would be harmful if the request was granted.

The health care provider must make a written statement, to be placed in the record, explaining why the request is denied. This statement shall include a description of the specific adverse or detrimental consequences to the patient which the provider anticipates would occur.

The health care provider must inform the person requesting records of the decision to refuse the request and of the right to give written authorization to a licensed physician, psychologist, or social worker to inspect the records on the requesting party’s behalf.

Any patient or representative may sue a health care provider to enforce the provisions of Section 123110 of the Health and Safety Code. The court may also award court costs and attorneys’ fees to the patient or representative if it finds the health care provider willfully violated these requirements.

OTHER INFORMATION AVAILABLE

USD Patient Advocacy Program

Patients’ Rights Handbooks (English and Spanish)

Minors’ Rights Handbooks

Patients’ Rights in Mental Health Facilities Posters

Medications and Your Right to Know

Seclusion and Restraint

Mental Health Services for Special Education Kids (AB 2726)

Your Rights as a Board & Care Resident

Conservatorship and You