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:

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

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."

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

Scans requested:

Please describe the scans you are requesting below.

Date of Service (mm/dd/yyyy)

Body Part Requested *

Additional Comments

Scan/Media Requested (please check all that apply) *

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

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.)

I knowingly and voluntarily authorize

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.

This authorization will expire on (mm/dd/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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Use form below for radiology records (X-ray/MRI).

Release my radiologic compact disks to:

Scans requested:

Authorization:

Purpose or reason for request:

How we helped our patients feel better.

"When I started with Bobby I had trouble with my back,laying in bed at night and with my left leg driving ...

Keith Malone

"Barbara was amazing! I came in barely able to move or walk or sit or lay down and she did her magic on ...

Tracy Gleason

"My shoulder was extremely stiff to the point where I could barely lift it. It was a struggle going to ...

King Peay

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 Radiology Records

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

Release my radiologic compact disks to:

Scans requested:

Authorization:

Purpose or reason for request:

How we helped our patients feel better.

"When I started with Bobby I had trouble with my back,laying in bed at night and with my left leg driving ...

Keith Malone

"Barbara was amazing! I came in barely able to move or walk or sit or lay down and she did her magic on ...

Tracy Gleason

"My shoulder was extremely stiff to the point where I could barely lift it. It was a struggle going to ...

King Peay

Request An Appointment

Request an Appointment