=====================================================================
*****FIRST REQUEST – delete this when preparing your own letter*****
=====================================================================

Your Name
Your Street Address
Your City, State ZIP
Your Phone Number
Your Email Address


Date


Doctor's Name
Doctor's Street Address
Doctor's City, State ZIP



Dear Dr. _________,


As per California Health & Safety Code Sections 123100-123149, I am requesting a copy of my medical records, including chart notes; pharmacy and durable medical equipment prescription records; laboratory test results; radiology, ultrasound and surgical reports; referral records; and any letters and reports from and to consulting or referring physicians.

I understand that your office is entitled to charge me reasonable costs for the copying of my records.  I will be happy to come in an assist with the photocopying, if that will help your office get my file copied and to me within the 15 days stipulated in the Code.  I will also be happy to pick up the copies from your office upon notification that they are ready to be picked up.

If you have any questions, please feel free to contact me.



Your Signature
Your Name
















=====================================================================
*****SECOND REQUEST – delete this when preparing your own letter*****
=====================================================================

Your Name
Your Street Address
Your City, State ZIP
Your Phone Number
Your Email Address


Date


Doctor's Name
Doctor's Street Address
Doctor's City, State ZIP

On [date of your original letter], I sent you a written request for copies of my medical records.  Your office signed for the registered letter on [date on returned receipt].

According to California Health & Safety Code Sections 123100-123149, I have the right to obtain copies of my medical records from [pick the best one: 'you' for a individual practitioner; for a group practice or clinic, put in the group practice or clinic name].
 
Code Section 123110(b) states providers have 15 days from the date of the request to transmit the copies to the requesting patient.  This code also states that the patient may request to review the records on site, and select those for which copies are wanted.  The provider is obligated to honor this request.  The provider may charge reasonable copying fees, as defined in the code for such copies.  

Code Section 123110(f) states that a provider defined under the code who "willfully violates this chapter is guilty of an infraction punishable by a fine of $100.  The state agency, board or commission that issued the health care provider's professional or institutional license shall consider a violation as grounds for disciplinary action with respect to licensure, including suspension or revocation of the license or certificate."

This is my second formal request for my records.  I expect to receive my medical records by [fifteen work days from the date you will be mailing this letter].  




Your Signature
Your Typed Name


cc:	Medical Board of California
	Your Attorney's Name, Esq.




Medical Board of California
1426 Howe Avenue, #54
Sacramento, CA 95825
http://www.medbd.ca.gov