California Code of Regulations
Title 16 - Professional and Vocational Regulations
Division 4 - State Board of Chiropractic Examiners
Article 2 - Practice of Chiropractic
Section 318 - Chiropractic Patient Records/Accountable Billings

Universal Citation: 16 CA Code of Regs 318

Current through Register 2022 Notice Reg. No. 14, April 8, 2022

(a) Chiropractic Patient Records. Each licensed chiropractor is required to maintain all active and inactive chiropractic patient records for five years from the date of the doctor's last treatment of the patient unless state or federal laws require a longer period of retention. Active chiropractic records are all chiropractic records of patients treated within the last 12 months. Chiropractic patient records shall be classified as inactive when there has elapsed a period of more than 12 months since the date of the last patient treatment.

All chiropractic patient records shall be available to any representative of the Board upon presentation of patient's written consent or a valid legal order. Active chiropractic patient records shall be immediately available to any representative of the Board at the chiropractic office where the patient has been or is being treated. Inactive chiropractic patient records shall be available upon ten days notice to any representative of the Board. The location of said inactive records shall be reported immediately upon request.

Active and inactive chiropractic patient records must include all of the following:

(1) Patient's full name, date of birth, and social security number (if available);

(2) Patient gender, height and weight. An estimated height and weight is acceptable where the physical condition of the patient prevents actual measurement;

(3) Patient history, complaint, diagnosis/analysis, and treatment must be signed by the primary treating doctor. Thereafter, any treatment rendered by any other doctor must be signed or initialed by said doctor;

(4) Signature of patient;

(5) Date of each and every patient visit;

(6) All chiropractic X-rays, or evidence of the transfer of said X-rays;

(7) Signed written informed consent as specified in Section319.1.

(b) Accountable Billings. Each licensed chiropractor is required to ensure accurate billing of his or her chiropractic services whether or not such chiropractor is an employee of any business entity, whether corporate or individual, and whether or not billing for such services is accomplished by an individual or business entity other than the licensee. In the event an error occurs which results in an overbilling, the licensee must promptly make reimbursement of the overbilling whether or not the licensee is in any way compensated for such reimbursement by his employer, agent or any other individual or business entity responsible for such error. Failure by the licensee, within 30 days after discovery or notification of an error which resulted in an overbilling, to make full reimbursement constitutes unprofessional conduct.

Cal. Code Regs. Tit. 16, § 318

Note: Authority cited: Section 1000- 4(b), Business and Professions Code (Chiropractic Initiative Act of California (Stats. 1923, p. 1xxxviii)). Reference: Section 1000- 4(b), Business and Professions Code (Chiropractic Initiative Act of California (Stats. 1923, p. 1xxxviii)).

1. New section filed 7-15-76; effective thirtieth day thereafter (Register 76, No. 29).
2. Renumbering of former Section 318 to Section 302(b) and new section filed 7-7-78; effective thirtieth day thereafter (Register 78, No. 27).
3. Amendment filed 2-5-80; effective thirtieth day thereafter (Register 80, No. 5).
4. Amendment of subsections (a) and (a)(6), new subsection (a)(7) and amendment of Note filed 3-8-2012; operative 4-7-2012 (Register 2012, No. 10).

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