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Request For Patient Access To Medical Records (California)

This is a request form for patient access to their medical records in California. The form letter provided here is simply a sample of what the actual form letter looks like.

REQUEST FOR PATIENT ACCESS TO MEDICAL RECORDS

I hereby request (name of physician, hospital or other healthcare provider)

___________________________, to give me access to medical information

for (patient's name) ___________________________.

SCOPE OF ACCESS REQUESTED

I would like access to:

• All the records or
• The portion of the records concerning:

(Specify type of disease, accident, dates of treatment, other portion of records you are interested in.)

TYPE OF ACCESS REQUESTED

• Inspection. Please call me and let me know when I may come to inspect the records, and the amount of the charge, if any.

• Copies. I would like copies of
- All records requested or
- All records other than X-rays or tracings

• Transfer. Please transfer
- Copies of all records requested or
- Original X-rays or tracings only

To: ___________________________ (Name and address of health care provider to whom the records are to be delivered)

CHARGES

Inspection. I understand that you may charge me for reasonable clerical costs incurred in making the records available for inspection.

Copies or Transfer. I understand that you may charge me a reasonable charge of up to twenty-five cents ($0.25) per page, or fifty cents ($0.50) per page for copies from microfilm, plus any additional reasonable clerical costs incurred in making the records available. I further understand that you may charge me your actual costs for copies of any X-rays or tracings derived from electrocardiography (E.K.G.), electroencephalography (E.E.G.) or electromyography (E.M.G.).

• I hereby agree to pay the charges specified above. Please bill me.
• Please call me to let me know how much this will cost.

Date: ___________________________

Signed: ___________________________

Print Name: ___________________________

Telephone: ___________________________

If not signed by the patient, please indicate relationship:

• parent or guardian of minor patient
• guardian or conservator of an incompetent patient
• beneficiary or personal representative of deceased patient


© California Medical Association 1999
As a public service of the California Medical Association, reproduction of this document by individuals for personal use and not for commercial purposes is authorized as long as each copy clearly includes this copyright notice.

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