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Medical records request letter generator. An Evidence Code 1158 request, ready to copy.

Write a California medical records request to a provider under Evidence Code 1158: records, billing and imaging, delivery, and the statutory copy costs.

The letter

[Firm name]
[Address, phone and email]

[Date]

[Provider name]
Attn: Custodian of Records

Re: Request for records under California Evidence Code section 1158
Patient: [Client name]
Date of birth: [Date of birth]
Dates of service: All dates of service

Dear Custodian of Records:

This office represents [Client name]. Enclosed is a written authorization signed by the patient (or the patient's legal representative) for the release of the records described below to this office. The authorization is written to meet the HIPAA Privacy Rule (45 C.F.R. section 164.508) and California Civil Code section 56.11.

Under Evidence Code section 1158(b), please make the following records available for inspection and copying:

1. The complete medical record for the dates above: intake and history forms, physician and nursing notes, consultation and operative reports, orders, medication records, laboratory results, therapy notes, discharge summaries and correspondence.
2. An itemized billing statement for the same dates, showing each date of service, the CPT or HCPCS code, the amount charged, and every payment, adjustment and write-off, with the payer's name.

This request does not include mental health records, alcohol or drug treatment records, or HIV test results unless the enclosed authorization specifically lists them.

The records are requested in electronic form. Under Evidence Code section 1158(g), where records are kept electronically, please provide them in the electronic form and format requested (searchable PDF) if readily producible, or in another readable electronic format we agree on. Please send them by secure electronic delivery to the contact below.

Under section 1158(b) and (d), the records should be made available during business hours within five days after the authorization is presented. If any part of the request will take longer, or if the records are held by an off-site storage vendor, please let us know who holds them and when they will be ready.

Reasonable costs may be charged to this office as section 1158(e) allows: ten cents per page for standard copies, twenty cents per page from microfilm, clerical time at no more than $16 per hour ($4 per quarter hour), actual postage, and any actual third-party retrieval charges. Please include an itemized invoice with the records.

If the patient has no records for the dates above, please say so in writing so that our file is complete.

Thank you for your help.

Sincerely,


[Attorney name]
[Firm name]

Enclosure: Authorization for disclosure of health information

Send it with the client's signed authorization. Section 1158 is the route before a lawsuit is filed or a defendant appears; after that, records usually come by subpoena with notice to the consumer. Check the letter against your own practice before it goes out. General information, not legal advice.

Everything is worked out in your browser; nothing you type is sent anywhere. General information about California and federal rules, not legal advice. Rules change and every case turns on its facts: check the statute and your own analysis before relying on a date or a figure.

What it writes

Fill in the firm, attorney, client, provider, dates of service, what you need (records, itemized billing, imaging) and how it should be delivered. The generator writes a request to the provider's custodian of records under California Evidence Code section 1158, citing the client's signed authorization. Blank fields show as bracketed placeholders. Nothing you type leaves the page.

The rule: Evidence Code section 1158

Before a lawsuit is filed or a defendant appears, an attorney (or the attorney's representative) who presents a written authorization signed by the patient is entitled to the patient's records. The authorization can also be signed by a guardian or conservator, a parent or guardian of a minor, or the personal representative or an heir of a deceased patient. The provider must promptly make all the patient's records in its custody or control available for inspection and copying (1158(b)).

If it doesn't make them available during business hours within five days after the authorization is presented, the provider may be liable for the reasonable expenses, including attorney's fees, of a proceeding to enforce the section (1158(d)). "Medical provider" covers physicians, dentists, nurses, therapists, chiropractors, pharmacists, licensed hospitals and others the section lists (1158(a)).

Three more parts of the section matter in practice:

  • Your own copy service. When the attorney employs a professional photocopier as the attorney's representative, the provider doesn't do the copying, and the copier's presentation of the authorization is proof that it acts for the attorney (1158(c)).
  • Electronic copies. If the records are kept electronically and you ask for an electronic copy, the provider must give it in the form and format requested if it's readily producible, or in a readable format you agree on (1158(g)).
  • The statutory form. A provider must accept a valid authorization printed in at least 14-point type in substantially the form the section sets out (1158(h)). That form leaves out mental health, alcohol or drug, and HIV test records unless they are specifically requested.

What it costs

ChargeLimit under section 1158
Standard copies, up to 8.5 by 14 inches$0.10 per page
Copies from microfilm$0.20 per page
Clerical time to locate and make records available$16 per hour, billed at $4 per quarter hour
PostageActual cost
Oversize documents or special processingActual cost
Retrieval and return of records held by a third partyActual cost
Records delivered for inspection or copying at the custodian's place of businessNo more than $15, plus actual third-party retrieval costs

These costs are charged to the requesting attorney (1158(e), (f)). For example, if a hospital copies 600 pages on paper and spends an hour locating them, the most the section allows for those items is $60 plus $16, plus actual postage.

The authorization

The letter refers to an authorization; it isn't one. The client's signed authorization has to satisfy two sets of rules:

  • HIPAA (45 CFR 164.508(c)). A description of the information, who may disclose it, who may receive it, the purpose, an expiration date or event, and the signature and date (with the representative's authority if someone else signs). It must also state the right to revoke in writing, whether treatment can be conditioned on signing, and that information disclosed may be redisclosed by the recipient. It must be in plain language.
  • California's Confidentiality of Medical Information Act (Civil Code 56.11). Handwritten or in at least 14-point type, separate from other language on the page and signed only to execute the authorization, stating the specific uses and limits, who discloses and who receives, an expiration date or event (one year or less unless the signer asks for a later date), and the right to receive a copy.

The 1158(h) form is written with these in mind. See HIPAA authorization in the glossary.

The patient-access route

A patient, or the patient's personal representative, can also ask for the records directly under Health and Safety Code section 123110. The provider must allow inspection within five working days and send copies within 15 days of the request, for a reasonable, cost-based fee limited to costs such as labor for copying and supplies (123110(a), (b), (j)). A provider can't withhold them over an unpaid medical bill (123110(i)). The section doesn't limit the rights an attorney has under section 1158 (123110(f)).

After a lawsuit is filed or a defendant appears, section 1158 no longer applies, and records usually come by subpoena, with notice to the patient. Our guide to California medical records request laws compares the routes.

What it leaves out

  • The authorization form itself.
  • Follow-up when a provider doesn't respond, and the enforcement proceeding section 1158(d) allows.
  • Records requests in workers' comp cases, and subpoenas after suit.
  • Special federal rules for some substance use disorder treatment records.

This is general information, not legal advice. Check the letter against your own practice before it goes out.

In PlaintiffStack

The Documents app builds a medical file of providers, visits, bills and missing records for a person to confirm, and a morning check flags record requests nobody has touched. Agents read searchable PDFs, Word and text files; scanned records and faxes aren't read yet, because there's no OCR. The records then feed the medical chronology. See the personal injury practice page.

Questions firms ask

Sources

  1. Evidence Code section 1158
  2. Health and Safety Code section 123110
  3. Civil Code section 56.11
  4. 45 CFR 164.508 (uses and disclosures requiring an authorization)

General information about California and federal rules, not legal advice. Rules change and every case turns on its facts: check the statute and your own analysis before relying on a date or a figure.

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