When she decided to switch her children's pediatricians recently, Liz Notter requested that her three young daughters' medical records be sent to their new pediatrician. But the doctors refused to release the records until Notter paid a $20-per-file fee--$60 total.

"They told me that they would not release the records until I had sent them a check and it had cleared," says the Gaithersburg mother. "Is this practice legal? Do I have any recourse against it? Is there any regulatory agency to which I could complain?"

It's no secret that the doctor-patient relationship is changing in today's health care turmoil. And while most of the hubbub over medical records lately is about confidentiality and privacy, an increasing willingness among patients-turned-consumers to change doctors has persuaded some physicians to charge for some services that traditionally were free. Just as doctors' house calls are a thing of the past, free transfer of medical records may be soon.

Charging for this service "is becoming more common," says American Medical Association spokeswoman Brenda Craine. "We do have an ethical policy on this: It says physicians can charge a reasonable fee for medical records."

The AMA's Code of Medical Ethics adds that "medical reports should not be withheld because of an unpaid bill for medical services" and that "the interest of the patient is paramount in the practice of medicine, and everything that can reasonably and lawfully be done to serve that interest must be done by all physicians who have served or are serving the patient."

Meanwhile, many states have passed laws that set limits on that "reasonable fee"--from as low as a dollar per page on up. "We've heard fees charged as high as $75" per file, Craine says.

The Maryland Medical Records Act, Section 4-304, requires health care providers to provide copies of medical records to patients who request them, says Stephen Johnson, general counsel and director of Law & Advocacy Division of the Baltimore-based Maryland State Medical Society.

The law also states that health care providers can charge up to $16.81 ($15 plus inflation adjustment since 1994) for preparing the records and 55 cents per page. Maryland also allows health care givers in most cases to withhold copying the records until the fee is paid.

But, Johnson adds, it is grounds for "licensure discipline" for a physician not to comply with the Medical Records Act--for instance, charging more than the prescribed rate. Patients can complain to Maryland's Board of Physician Quality Assurance at 410-764-4777 or 800-492-6836.

Bill Cimino, communications director of the Medical Society of Virginia, based in Richmond, says Virginia law allows doctors to charge patients up to 50 cents per page for the first 50 pages, and 25 cents per page thereafter, for copies of their medical records. Microfilm copies go for a dollar a page; X-rays are included at cost.

"The doctor may also charge for all shipping as well as a $10 handling fee," says Cimino. Virginia patients can complain to the Virginia Board of Medicine at 804-662-9908 or 800-533-1560 (in Virginia only).

District health care providers can charge for the costs of copying and delivering medical records, says Rosey Blakely, spokeswoman for the D.C. Medical Society. Patients with complaints or concerns about physicians in the District can write to the Medical Society's professional standards committee, 2175 K St. NW, Suite 200, Washington, D.C. 20037.