Request Medical Records

Use form below for medical records.

If you would like to receive a copy of your medical records from Orlin & Cohen, please complete the form below. If you have any questions, please contact our Medical Records Department at 516.881.7525 or fax 516.881.7586. Patient records can be picked up during office hours between 10am-2pm.

Please complete the following information in its entirety:

Request Medical Records
  • Release my information to:

    If you are requesting that we send your information to another party, please complete this section in its entirety. If you are requesting that your information be sent to you, please write "SELF" in the first box below to "Person/Company Name."

  • Authorization:

  • Purpose or reason for request:

  • I knowingly and voluntarily authorize the Orlin & Cohen Orthopedic Associates LLP, and its employees and agents to use and/or disclose protected health information (PHI) about me in the manner described in this authorization. (If you are a patient you may type "My personal request" in the box.)
  • When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the Federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to Orlin & Cohen Orthopedic Associates LLP, 444 Merrick Road, Suite 230, Lynbrook, NY 11563. Attention: Medical Records Request.

    I understand that there is a fee associated with the requests for records. This fee will be invoiced to the requestor and is required to be paid prior to the request being processed. Methods of payment accepted are cash, check and credit card. Our standard fee is 0.75 per page.

    By clicking the submit button below, I acknowledge that I have read this authorization and understand its terms. I also acknowledge that I am lawfully permitted to request the information listed above as well as authorize Orlin & Cohen Orthopedic Associates. LLP, its employees and agents to process this request.
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  • Once your request has been received, we will call to verify that you have requested your records. We will only call the number we have on file in your account.
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