Accessing Your Patient Records
Can patients receive copies of their records?
YES. People are often confused about who is entitled to X-rays. The law states that if the dentist has, at the patient's new dentist's request, sent the original X-rays to the new dentist, he or she is not required to provide copies to the patient. Dentists who don't wish to part with the original X-rays may provide the patient with copies to give to the new dentist.
Can the patient be charged for the copies?
YES. The dentist is entitled to charge a reasonable fee based upon the actual time and cost involved in preparing the summary.
Must the patient clear up any outstanding account before receiving copies of their records?
NO. Dentists may not demand an outstanding account be cleared before providing access to records. However, there are other mechanisms by which the account balance may be pursued.
What exactly is the patient entitled to receive?
The law regulating patient right to access to medical records is found in the California Health and Safety Code Section 12300-123149.5. It gives patients the right to:
- Inspect records during business hours within five (5) days of presenting a written request.
- Receive copies of records within 15 days of presenting a written request.
- Receive x-rays or tracings within 15 days of presenting a written request.
The law gives the dentist the right to:
- Charge a reasonable clerical cost for locating and making the records available.
- Charge $.25 per page (or $.50 per page for microfilm copy), as well as reasonable clerical costs, for copies.
- Charge reasonable costs, not exceeding actual duplication cost, for x-ray copies.
- Prepare a summary of the records as an alternative to providing copies or allowing inspection.
If the summary option is exercised, the summary must be provided within ten (10) working days of the patient's request, thirty (30) days for extraordinarily long records or if the patient has been discharged from a licensed health facility within the last ten (10) days. It must include the chief complaint(s) with pertinent history; findings from consultations and referrals to other health care providers; diagnosis, where determined; treatment plan and regiment, including medications prescribed; progress of treatment; prognosis, including significant continuing problems or conditions; pertinent records of diagnostic procedures and tests and all discharge summaries; objective findings from the most recent physical exam, such as blood pressure, weight and actual values from routine laboratory tests; and a list of all currently prescribed medications, including dosages, and sensitivities or allergies to medications recorded by the dentist.
If a summary is provided, the dentist may confer with the patient to determine why the patient wants the records. If the information required relates only to specific injuries, illnesses or episodes, the summary need only relate to those items.