SAMPLE
FORM
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:
-
o All
the records
o 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
o Inspection. Please call me and let me know when I may come to inspect
the records, and the amount of the charge, if any.
o Copies. I would like copies of
oTransfer. Please
transfer
- o Copies
of all records requested or
o 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
(EKG), electroencephalography (EEG) or electromyography (EMG).
- I hereby agree
to pay the copying charges specified above.
- Please
bill me.
- o Please
call me to let me know how much these copies will cost.
-
I am requesting
these records to appeal the denial of eligibility for Medi-Cal, SSDI or SSI/SSP
benefits. A copy of the program’s denial notice is attached. I applied
for these benefits on ___________ (date).
Signed:__________________________ Date:_______________
Print Name:_______________________
Telephone:______________
If not signed by the patient, please indicate relationship:
o parent or guardian of minor patient
o guardian or conservator of an incompetent patient
o beneficiary or personal representative of deceased patient
© California Medical Association 1995-2002
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.
