Request Radiology Records

Use form below for radiology records (X-ray/MRI).

Patient records can be picked up during office hours between 10am-2pm

Please complete the following information in its entirety:

Request Radiology Records
  • 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 box below next to "Person/Company Name."

  • Scans requested:

    Please describe the scans you are requesting below.

  • MM slash DD slash YYYY

  • 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 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.
  • MM slash DD slash YYYY
  • 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.
    • gform 7 Submit

    * Required Fields

    building logo

    Our offices across Long Island are open for in-person visits with new protocols for immediate, personalized care in the safest possible environment.

    Learn More learn-more-arrow

    How we helped our patients feel better.

    Read Patient Reviews learn-more-arrow Share Your Story learn-more-arrow
    • Maria Sequeira

      "I had injured my right hamstring several years ago. I went through a series of acupuncture ,cupping, ...

      Maria Sequeira

      Procedure

      PRP

      Performed By

      James Paci, M.D.

    • Stephen Pavao

      "Dr. Wu and Lianna D’Ambrosio my OTR were absolutely incredible! They were so knowledgeable letting ...

      Stephen Pavao

      Procedure

      Elbow wrist tendinitis

      Performed By

      Tiffany Wu, M.D.

    • Linda Orlando

      "I started physical therapy in your Port Jefferson location to try to alleviate the pain and uncertain ...

      Linda Orlando

      Procedure

      Physical Therapy

      Performed By

    Hero Shape

    * Required Fields