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:

First Name * Required
Last Name * Required
Phone * Required
Email
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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."

Pick Up or Mail

Pick Up
Mail

Pick Up Office Location

Person/Company Name *

Phone

Fax

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Information to be disclosed *

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.)

Purpose or reason

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.

This authorization will expire on (mm/dd/yyyy)

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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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"Ali was the perfect therapist for me - pushing me when I need it to achieve best results, answering my ...

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Request Medical Records

Use form below for medical records.

Release my information to:

Authorization:

Purpose or reason for request:

How we helped our patients feel better.

"This young lady is fantastic!!! She helped me so much!! I still have some time to go, but I feel confident ...

Richard Wilson

"I had a partial tear in my patellar tendon, and I didn't know if I would be able to play basketball again ...

Christian Prince

"Ali was the perfect therapist for me - pushing me when I need it to achieve best results, answering my ...

Cindy Gurmann

Request An Appointment

Request an Appointment

Looking for the best in orthopedic care?

We’ve Got The Most Top Specialists For That

Looking for the best in orthopedic care?

We’ve Got The Most Top Specialists For That

Request Medical Records

Use form below for medical records.

Release my information to:

Authorization:

Purpose or reason for request:

How we helped our patients feel better.

"This young lady is fantastic!!! She helped me so much!! I still have some time to go, but I feel confident ...

Richard Wilson

"I had a partial tear in my patellar tendon, and I didn't know if I would be able to play basketball again ...

Christian Prince

"Ali was the perfect therapist for me - pushing me when I need it to achieve best results, answering my ...

Cindy Gurmann

Request An Appointment

Request an Appointment