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Request Radiology X-Ray/Magnetic Resource Image (MRI) Records

Please complete the following information in its entirety.

* indicates required fields.






   


Release my Radiologic compact disks 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 next to "Person/Company Name."




   



Scans Requested:

Please describe the scans you are requesting below.




 X-Ray Compact Disk
 Magnetic Resource Image (MRI) Compact Disk


Authorization:

In the event that any of the foregoing information contains mental health records, genetic information, venereal disease-related records, tuberculosis-related records, drug and alcohol treatment records, and /or HIV/AIDS-related diagnosis and treatment information, I specifically authorize release of such information (by checking this box you agree).


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 104, Lynbrook, NY 11563. Attention: Medical Records Request.

I understand that there is a fee associated with the requests for compact disks. 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.

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 The Orlin & Cohen Orthopedic Group, its employees and agents to process this request.


Once your request has been received we will call to verify that you have requested your radiology records. We will only call the number we have on file in your account. We will forward you an invoice with the total amount due. For X-Rays, an all inclusive compact disk costs $10.00 per disk. There is a 3 to 5 day processing time after payment is received. For MRI compact disks, the first copy is given at no charge. Additional copies are $8.00 per disk.