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MEDICAL INFORMATION AND RECORD RELEASE
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To protect patient confidentiality, no patient information or medical record should be released without written authorization from the patient (if living) or from the patient's legal/personal representative (if patient is deceased or incompetent).
WHAT DOES THE MEDICAL RECORD INCLUDE?
In California, patients have the right to examine their medical record and/or obtain a copy. The medical record also includes items such as x-rays, lab reports, and videotapes. Billing records, if requested, must also be provided.
Appointment books, registers and logs are not part of the medical record.
The physician may prepare a summary of the medical record as an alternative, if acceptable to the patient/family.
WHAT AUTHORIZATION IS REQUIRED FOR RELEASE OF A MEDICAL RECORD?
- A written authorization/form is required for inspection and/or release of a medical record. The language for release should allow release by mail, telephone, and/or facsimile (fax).
- A valid record authorization must meet specific language requirements to release records to anyone other than the patient. To release records to a patient, only the patient's handwritten, signed request is needed.
- Release only copies of the medical record (including notes, x-rays, videos, etc.).
- A reasonable clerical fee, plus up to 25¢ per page, may be charged for copying the medical record.
- Requests for the medical record may indicate a potential problem. Develop a system to make the physician aware of requests.
- Requests to inspect the record must be honored within 5 working days and copies released within 15 days after receiving the written request and a reasonable fee to defer copy costs.
- Document in the medical record the date and to whom the record was released.
- A separate, signed authorization to release must be obtained for each request.
- If the record is faxed, the fax transmittal form should clearly identify to whom the record is sent by name, office and fax telephone number, address, and include a confidentiality statement.
Example: "This message is intended only for the use of the individual or entity to which it is
addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the above address via the U.S. Postal Service. Thank you."
SPECIAL CONSIDERATIONS:
Some situations have special rules that apply and require specific authorization (information and records regarding testing and treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/substance abuse).
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This information is not intended to be all-inclusive. If you have a specific patient situation, please contact CAP/MPT Risk Management at (800) 252-7706 for further information.
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