Patient Records Policy

Can patients receive copies of their records? 

Yes.  Patients and their representatives have the right to access their records.  Patients are not limited in the number of requests for access to, or copies of, records.

Copies of x-rays need not be provided to the patient if the original x-rays are transmitted to another dentist at the request of the patient.

Can the patient be charged for the copies? 

Yes.  Copying charges may not exceed specified limits.  A reasonable charge for clerical costs involved in making the record or copies available is allowed.

Many dentists forgo charging a fee if they transmit the records directly to another dentist.

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 123100-123149.5.  It gives patients the right to:

• Inspect records during business hours within five days of presenting a written request.
• Receive copies of records 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 working days of the patient’s request, 30 days for extraordinarily long records or if the patient has been discharged from a licensed health facility within the last ten 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 regimen, 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.