Physical Therapy Board of California

Patient Access to Medical Records

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California Health & Safety Code Section 123100 et seq. establishes a patient's right to see and receive copies of his or her medical records, under specific conditions and/or requirements as shown below. The law only addresses the patient's request for copies of his or her own medical records and does not cover a patient's request to transfer records between healthcare providers or to provide the records to an insurance company or an attorney. The request to transfer medical records is considered a matter of "professional courtesy" and is not covered by law. No statutes cover record transfers and there is no set protocol for transferring records between providers. Generally, physical therapy records may be transferred without charging a fee; however, some physical therapy offices do charge a fee associated with copying and mailing the paperwork. As the patient, you will be required to sign a records release form to transfer records.

If you have followed the requirements outlined in the Health & Safety Code and the physical therapist has not complied with your request, you may file a complaint with PTBC. The physical therapist will be contacted to determine the reason for failing to provide you with access to your medical records.

Section 123110 of the Health & Safety Code specifically provides that any adult patient, or any minor patient who by law can consent to medical treatment (or certain patient representatives), is entitled to inspect patient records upon written request to a physical therapist and upon payment of reasonable clerical costs to make such records available. The physical therapist must then permit the patient to view his or her records during business hours within five working days after receipt of the written request. The patient or patient's representative may be accompanied by one other person of his or her choosing. Prior to inspection or copying of records, physical therapists may require reasonable verification of identity, so long as this is not used oppressively or discriminatorily to frustrate or delay compliance with this law.

The patient or patient's representative is entitled to copies of all or any portion of his or her records that he or she has a right to inspect, upon written request to the physical therapist. The physical therapist may charge a fee to defray the cost of copying, not to exceed 25 cents per page or 50 cents per page for records that are copied from microfilm, along with reasonable clerical costs. By law, a patient's records are defined as records relating to the health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient. Physical therapists must provide patients with copies within 15 days of receipt of the request.

A physical therapist may choose to prepare a detailed summary of the record pursuant to Health & Safety Code section 123130 rather than allowing access to the entire record. This summary must be made available to the patient within 10 working days from the date of the patient's request. If more time is needed, the physical therapist must notify the patient of this fact and the date that the summary will be completed, not to exceed 30 days between the request and the delivery of the summary.

If the patient specifies to the physical therapist that he or she is interested only in certain portions of the record, the physical therapist may include in the summary only that specific information requested. The summary must contain information for each injury, illness, or episode and any information included in the record relative to: chief complaint(s), findings from consultations and referrals, diagnosis (where determined), treatment plan and regimen including medications prescribed, progress of the treatment, prognosis including significant continuing problems or conditions, pertinent reports of diagnostic procedures and tests and all discharge summaries, and objective findings from the most recent physical therapist examination, such as blood pressure, weight, and actual values from routine laboratory tests. The summary must contain a list of all current medications prescribed, including dosage, and any sensitivities or allergies to medications recorded by the physical therapist.

There are some exceptions to the absolute requirements shown above: a physical therapist may refuse the request of a minor's representative to inspect or obtain copies of the minor's records if a physical therapist determines that access to the patient records requested by the representative would have a detrimental effect on the physical therapist's professional relationship with the minor patient or the minor's physical safety or psychological well-being.