Please complete the following information in its entirety.

  • Date Format: MM slash DD slash YYYY
  • Address
  • 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."

  • Address
  • Scans requested:

    Please describe the scans you are requesting below.

  • Date Format: MM slash DD slash YYYY
  • Scan/Media Requested (please check all that apply) * Required
  • 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.
  • Date Format: 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.

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What Our Patients Are Saying

View All Testimonials learn-more-arrow
  • VinceTuranosmallfile_150x150_acf_cropped
    "After having knee surgery in 2009 with a tremendous outcome with Orlin and Cohen's Dr. Eric Price, I ...

    Vince Turano

    Procedure

    Knee Surgery, Arm Surgery

    Performed By

    Bennett H. Brown, M.D.,Eric Price, M.D.

  • "I was referred to Dr. Jonathan Ticker by a friend who was treated for a shoulder impingement and pleased ...

    Rob. S

    Procedure

    Shoulder Surgery

    Performed By

    Jonathan B. Ticker, M.D.

  • "Dr. Krochak provided exceptional care from initial consultation to surgery follow up.  I was able to ...

    Adam M.

    Procedure

    Meniscus Surgery

    Performed By

    Ryan Krochak, M.D.

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Request an Appointment

During this crisis, we’re treating patients with urgent issues only. For the health and safety of our patients, staff and community, we’re temporarily becoming an “on-call” only practice—offering both in-person and telehealth visits—for those with urgent orthopedic issues by appointment only. Call 516-536-2800 or 631-706-2800 and a member of our orthopedic team will work with you to assess whether you need immediate attention. Learn more
To schedule a new appointment in the near future, please fill out the form below. We will respond as quickly as possible. To request a follow-up appointment, click here.

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