Various state and federal laws allow patients in California to have direct access to their medical record information, either by inspection, obtaining copies, or receiving a summary of their care. The following information is furnished to help answer questions you may have regarding this process.
What records do the laws cover?
Basically, the laws permit access to any medical record in the possession of any health care provider. The term “health care provider” applies to almost every licensed health care facility or health care professional in the state. For example, it could be an acute care hospital, a psychiatric hospital, a skilled nursing facility, a physician, a psychiatrist or psychologist, a chiropractor, or a licensed social worker.
How do I request access?
All requests must be in writing; no telephone requests can be accepted. Your written request should be on the Langley Porter Request for Patient Access to Medical Record Form that contains fill-in spaces for the information necessary to help us identify your record in the event that there are other patients with a name similar to yours.
When requesting copies, you should also indicate what parts of the record you want. To request the necessary form, you can telephone (415) 476-7330, or complete the form and return to the address below.
What is meant by “inspection” and “summary”?
Inspection means that you can come to Langley Porter Psychiatric Hospital & Clinics (LPPH&C) to review the record by appointment only. Review is limited to one hour and will be supervised by an LPPH&C employee during the appointment.
Two alternatives to inspection are the preparation of a summary or a verbal explanation of the care given to you. Before either of these alternatives are chosen, you must approve of the alternative and agree to pay any related fees associated with the alternative chosen.
Am I the only one who can have access to my records?
An adult patient is the only one with access to the record, unless there is a conservatorship of the person, in which case the conservator has the right of access as the patient’s representative. If the patient is a minor, the parent or guardian has access unless the minor had the right of consent to the treatment given, in which case the minor patient has the right of access.
How will my identity be verified?
Before you will be allowed access to your medical record, your identity will be verified. If you are the patient or the married parent of a patient, you will be required to show a picture ID. If you are a minor’s divorced parent, you will be required to show a picture ID and court papers showing custody arrangements. If you are a guardian or conservator, in addition to a picture ID, you will be required to present court papers showing guardianship or conservatorship.
Are there any limitations?
The laws describe certain types of information that are not considered to be part of the medical record (e.g., information regarding another patient or aggregate information about many patients). By law, the clinician can deny your request for psychiatric records if they believe that there may be significant adverse consequences of such disclosure. If access is denied on this basis, you may then name a licensed physician, licensed clinical social worker, or licensed clinical psychologist to inspect the record. The clinician may also deny access to the parent or guardian when it is believed that such disclosure will have a detrimental effect on the treatment relationship with the minor patients. Federal regulations place some additional limitations on access to alcohol and drug abuse records.
What will it cost me?
The law allows us to recover our costs involved in providing copies. If copies are requested, there will be a charge of $0.25 per single sided paper page and $15.00 postage and handling. Since most medical records are lengthy, you may want to consider just what your actual needs are and limit your request for copies to those specific items, rather than requesting the entire record. We will also charge a reasonable fee for the clinician’s time spent in preparing a summary alternative (either verbal or written).
For purposes related to appealing a decision on eligibility from one of the following public benefit programs: Medi-Cal and Social Security disability insurance benefits and Supplemental Security Income/State Supplementary Program for the Aged, Blind and Disabled, the law allows you access to one free copy of the relevant portions of the medical record upon written request and proof that the records are needed to support an appeal.
Do I have to pay in advance?
Yes. The law makes access conditional upon the pre-payment of allowable charges and we will expect to be paid prior to inspection or copying. If you have requested copies, we will send you a statement of expected charges before making the copies so that you will have an opportunity to change your request if the charge is greater than anticipated.
How soon will I have access?
The law specifies that inspection must be permitted within five working days and copies must be available within 15 days after a valid written request is received by us. If we choose to furnish the summary alternative, it will be available within 10 working days, but this time may be extended to 30 days if the record is lengthy or if you have been discharged from the hospital within the previous 10 days. If this extension is necessary, you will be notified. Your request will not be considered valid until the information furnished is adequate to identify the record properly and payment is made for requested copies.
Are there other ways I can obtain information from my medical record?
Yes. Physicians and hospitals ordinarily furnish information necessary to continue your care when it is requested by another physician or hospital. If your insurance company, school, employer, or other third party needs information from your record, it is preferable to let them request it directly as they can be more precise about what they need. The third party who has requested the information usually pays any charges for information furnished in this way. Such requests will require a valid written consent from you to release the information. To give this consent, complete the Authorization for Release of Medical and Mental Health Information Form and return to the address below.
Your authorization for release of confidential information should include the following:
- Patient name and date of birth
- Name of person or agency to receive the information
- The specific information that is to be released
- Uses for which it is being released
- Any limitations you want to place on the release
- A date when the authorization will expire
- Your signature and date signed
If requesting medical records information, please complete the forms above and send to:
Langley Porter Psychiatric Hospital & Clinics
Attn: Medical Records
University of California, San Francisco
401 Parnassus Avenue
San Francisco, CA 94143-0984