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Performed By Select a Doctor No Prefered Doctor Robert Abiuso, OTR/L Scott W. Alpert, M.D. Meylin Amador, PTA (Senior PTA) Briana Ardolino, MOT, OTR/L, CHT Eugene Arena, M.S.N., FNP-BC Felross Arimas, PT, DPT Hamlet Aristy BS/MS, OTR/L Bryan Baracaldo, PT, DPT Jonathan Belmonte DPT, SCS De’Zhane Bennett, PTA Leslie Anne Bernstein, PT, DPT, LMT Olivia Bolen, PT, DPT, OCS, CSCS Todd Bornfriend, PT Matthew R. Boylan, M.D., M.P.H. Justin Brain, PTA Kathleen Brooks, MS, PT, ART Bennett H. Brown, M.D. Jill M. Byrnes, MSPT Tara Congimi, OTD, OTR/L, CHT Daniel Crowe, MSOT, OTR/L, CHT Dana L. Cruz, M.D. James Curley, PT, DPT, ATC Lianna D’Ambrosio, MS, OTR/L Leonardo D’Onofrio, MS, PT Cheryl E. Daves, M.D. Stephen R. Densen, D.P.M. Anthony DeRosa, MA, PT Pierre Dieudonne, PTA Samantha DiMaio, OTR/L, CHT Matthew Dobkowski, DPT, ATC, CSCS Eileen Duswalt-Agostino PT, MPT Stephanie Edwards, PT, DPT Alfred F. Faust, M.D. John Feder, M.D. Barbara Feehan, PT Robert Fisch, M.D. Michael J. Fracchia, M.D., A.B.O.S., F.A.A.O.S Nicholas Friedell, PTA Robert Gadsden, PTA Katherine Gallagher, OTR/L Garret Garofolo, M.D. Bradley Gerber, M.D. Christopher Geremia, PTA James A. Germano, M.D. Brian Goldstein, D.O. Jeffrey A. Goldstein, M.D. Kathleen M. Graustein, PT, GCS June C. Halsey, M.D. Alyas Hamid PT, DPT, OCS Chelsea Harms, PTA Alicia Hershkowitz-Epstein, MS, OTR/L, CHT John D. Hubbell, M.D. Alexander Kapoutsos PT, DPT Matthew Kavanaugh, PT Eric P. Keefer, M.D. Nicole Kerr, PT, DPT Henryk Kielsznia, PT, MPT, Cert. MDT Jared Kipnis PT, DPT, COMT, ART Scott Koenig, M.D. Ryan Krochak, M.D. Roxana Lazo, PTA Brett A. Lenart, M.D. Kim Leogrande, PTA Patrick Leung, M.D. Craig Levitz, M.D. Catherine Liang PT, DPT Gregory Lieberman, M.D. Robert J. Lippe, M.D. Amira Lisle, DPT Lewis Lupowitz, DPT, CSCS, FRCmS Danielle Magrini, D.O., F.A.A.P., CAQ-SM Jeffrey E. Mait, M.D. Tatiana Malkina, PT, DPT, OCS, COMT Gregory C. Mallo, M.D., F.A.A.O.S. Moiz Manaqib, M.D. Henry Marano, M.D. Christine Masterson, PT, DPT, MCMT, CLT Sunita Mathew PT, DPT Christopher McCormack PTA, CES, FRCms, FMS Danielle McCormick, PT, DPT Brian J. McGinley, M.D. Shelby McKinney, PTA Frenny Mehta, PT, DPT Brian Mercer, M.D., M.S. Charles Milchteim, M.D. Jamie Misegades, PT, DPT Joshua T. Mitgang, M.D. Angela Monaco, PT, DPT Brian N. Morelli, M.D Anthony Morelli, PTA Joseph D. Munn, M.D. Michele Murphy, PT, DPT, SFMA Bobby Nabeyama, PT, DPT, MS Claire Nurse, OTR/L, CHT Julie O’Lansen, PTA, GTS Stacy Oster, MS, OTR/L, CHT James Paci, M.D. Arthur Pallotta, M.D. Dr. Marco Palmieri, D.O. Darlene Pappalardo, OTR/L Jerry Mathai Parackel, PTA Bryan Paul, DPT, SCS, CSCS Ronny Paulino, PTA Jordan Placella PT, DPT, GTS Kathleen Polak, PT, DPT Francesco Policaro, PT, DPT, ART Ryan Power, PT, DPT Eric Price, M.D. Michael Procaccini, MS, PT Eric A. Putterman, M.D. Rasel M. Rana Wayne Reizner, M.D., M.B.A. Walter Rho, M.D. Nina Ribeiro, PTA Rosario Riccabene, PTA Stephanie Ringbauer PT, DPT Brandon Rooney, M.S.N., FNP-C April Rosenberg, PTA Alex A. Rothfeld, M.D. Barry Rubin, M.D., F.A.A.P.M.R. Anthony Sansotta, PT, DPT Dorothy Scarpinato, M.D. Kimberly Scheid, PT, DPT Philip Schrank, M.D. Kang Seo, PT, DPT Alpesh Shah, M.D. Ravi Shah, M.D. Marc Sheinblum, PT, DPT Jeffrey S. Sider, M.D. Dana Silbert PT, DPT Taylor Simeone, PTA Alexandra Smaguin, PT, DPT, ATC, CSCS, CIDN Neal Smith, M.D. Julian J. Sonnenfeld, M.D. Vincent Sperandeo, D.N.P. Samantha Speziale, PT, DPT John M. Stamatos, M.D. Mark Stephen, M.D. Tony Tang, PT, DPT Andrew A. Tarleton, M.D. Jonathan B. Ticker, M.D. Elena Triboy, PTA Donna Trimarco, M.S., ANP-C Liffy Varghese, PTA, CES, PES Jessica Velez, PT, DPT Lia Velys PT, DPT Richard Viskewich, PTA Imran Wahedna, M.D., F.A.C.P. Christopher Wallace, PT, DPT Christopher Wild, DPT, SCS, CSCS Tiffany Wu, M.D. Daniel Yadegar, M.D. John J. Yu, M.D. David I. Zaret, M.D., M.B.A.
Physical or Occupational Therapist Select a Therapist No Prefered Therapist Robert Abiuso, OTR/L Meylin Amador, PTA (Senior PTA) Briana Ardolino, MOT, OTR/L, CHT Felross Arimas, PT, DPT Hamlet Aristy BS/MS, OTR/L Bryan Baracaldo, PT, DPT Jonathan Belmonte DPT, SCS De’Zhane Bennett, PTA Leslie Anne Bernstein, PT, DPT, LMT Olivia Bolen, PT, DPT, OCS, CSCS Todd Bornfriend, PT Justin Brain, PTA Kathleen Brooks, MS, PT, ART Jill M. Byrnes, MSPT Tara Congimi, OTD, OTR/L, CHT Daniel Crowe, MSOT, OTR/L, CHT James Curley, PT, DPT, ATC Lianna D’Ambrosio, MS, OTR/L Leonardo D’Onofrio, MS, PT Anthony DeRosa, MA, PT Pierre Dieudonne, PTA Samantha DiMaio, OTR/L, CHT Matthew Dobkowski, DPT, ATC, CSCS Eileen Duswalt-Agostino PT, MPT Stephanie Edwards, PT, DPT Barbara Feehan, PT Nicholas Friedell, PTA Robert Gadsden, PTA Katherine Gallagher, OTR/L Christopher Geremia, PTA Kathleen M. Graustein, PT, GCS Alyas Hamid PT, DPT, OCS Chelsea Harms, PTA Alicia Hershkowitz-Epstein, MS, OTR/L, CHT Alexander Kapoutsos PT, DPT Matthew Kavanaugh, PT Nicole Kerr, PT, DPT Henryk Kielsznia, PT, MPT, Cert. MDT Jared Kipnis PT, DPT, COMT, ART Roxana Lazo, PTA Kim Leogrande, PTA Catherine Liang PT, DPT Amira Lisle, DPT Lewis Lupowitz, DPT, CSCS, FRCmS Tatiana Malkina, PT, DPT, OCS, COMT Christine Masterson, PT, DPT, MCMT, CLT Sunita Mathew PT, DPT Christopher McCormack PTA, CES, FRCms, FMS Danielle McCormick, PT, DPT Shelby McKinney, PTA Frenny Mehta, PT, DPT Jamie Misegades, PT, DPT Angela Monaco, PT, DPT Anthony Morelli, PTA Michele Murphy, PT, DPT, SFMA Bobby Nabeyama, PT, DPT, MS Claire Nurse, OTR/L, CHT Julie O’Lansen, PTA, GTS Stacy Oster, MS, OTR/L, CHT Darlene Pappalardo, OTR/L Jerry Mathai Parackel, PTA Bryan Paul, DPT, SCS, CSCS Ronny Paulino, PTA Jordan Placella PT, DPT, GTS Kathleen Polak, PT, DPT Francesco Policaro, PT, DPT, ART Ryan Power, PT, DPT Michael Procaccini, MS, PT Nina Ribeiro, PTA Rosario Riccabene, PTA Stephanie Ringbauer PT, DPT April Rosenberg, PTA Anthony Sansotta, PT, DPT Kimberly Scheid, PT, DPT Kang Seo, PT, DPT Marc Sheinblum, PT, DPT Dana Silbert PT, DPT Taylor Simeone, PTA Alexandra Smaguin, PT, DPT, ATC, CSCS, CIDN Samantha Speziale, PT, DPT Tony Tang, PT, DPT Elena Triboy, PTA Liffy Varghese, PTA, CES, PES Jessica Velez, PT, DPT Lia Velys PT, DPT Richard Viskewich, PTA Christopher Wallace, PT, DPT Christopher Wild, DPT, SCS, CSCS
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Consent for Publishing Photographs and/or Recordings
1. I, the undersigned, a participant in the production and videotaping (or other recording) at Orlin & Cohen Orthopedic Group (or the parent, legal guardian, or person otherwise authorized to consent to such participation), hereby consent to the taking of any and all still photographs, motion pictures, television and/or videotapes, voice recording, and/or other recordings ("Recordings") of my/his/her person at Orlin & Cohen (the “Practice”) during the course of my/his/her participation in (the "Event") agree to the use of the Recordings as follows:
For any educational, training, contribution solicitation, marketing, promotional or other purpose, in any medium whatsoever, by the Practice and/or by any person or persons the Practice may name: and/or for any broadcast or other public viewing. Such Recording may be used as described above, in full or edited form, and may be incorporated into other recording or formats and may be copied for multiple distributions and/or broadcast.
2. I agree that I will receive no compensation or other remuneration for the taking, production, use, broadcast, and/or distribution of such Recordings or for my participation in any manner in such Event, and I specifically release the Practice and all others from any liability or other obligation arising from the taking, production, use, broadcast, and/or distribution of such Recordings and from my participations in the Event.
3. I understand that I have the right to withdraw from participating in the Recording at any time during the Event and that I have the right to revoke this consent at any time to the extent that the Practice and/or its designee have not relied upon it or has not submitted the Recording for use in external media.
Note: If the participant is under (18) years, the permission of the participant’s parent, legal guardian, or authorized person is required. If the participant decides to revoke his or her authorization, please write to Orlin & Cohen Orthopedic Group, 1728 Sunrise Highway, Merrick, NY 11566, as soon as that decision is made.
Terms and Conditions
INDIVIDUAL AUTHORIZATION FOR RELEASE OF INFORMATION
We understand that information about you and your health is personal and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your written authorization before we may use or disclose your protected health information for the purposes described below. This form provides that authorization and helps us make sure that you are properly informed of how this information will be used or disclosed. Please read the information below carefully before agreeing to the terms of this authorization.
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION
Who will use and disclose my information? Orlin & Cohen will disclose the information you submit about your Orlin & Cohen experience by electronically posting it to www.orlincohen.com and/or Orlin & Cohen social media channels. Orlin & Cohen will send you messages regarding the status of your submission through the email service provider of Orlin & Cohen’s choosing. Orlin & Cohen may use the information you submit to contact you to request permission to use the information you submit about your Orlin & Cohen experience for other purposes. Orlin & Cohen may also use the information you submit about your Orlin & Cohen experience for: (i) educational, training, and/or promotional purposes at Orlin & Cohen and/or at any other location(s); (ii) publicity, advertising (print, digital, and/or television), publications, and/or solicitation of contributions; and/or (iii) broadcast and/or other public display or viewing.
Who will see my information? Anyone visiting www.orlincohen.com and/or Orlin & Cohen social media channels may see or use the information you submit. Administrators of the email service provider Orlin & Cohen uses to send you status messages will also have access to limited information, primarily your email address. In addition, in the event Orlin & Cohen uses your information as described above members of the general public will see the information.
What information will be used or disclosed? The information used and disclosed will be limited to the information you submit through this website. The information posted/disclosed on www.orlincohen.com and/or Orlin & Cohen social media channels, or otherwise used and/or disclosed as described above, may include:
Your name
The city/town, state/province/territory, and country where you live
The story of your care at Orlin & Cohen with information on your condition/injury, diagnosis, and treatment (including surgery if applicable)
The name of your Orlin & Cohen physician(s), therapist(s) and other caregivers; and your photo and/or video
The information disclosed to Orlin & Cohen's email Service provider, and used by Orlin & Cohen to contact you, will include your:
If you submit sensitive information, that information will be deleted from your submission prior to your story being posted to www.orlincohen.com and/or Orlin & Cohen social media channels, or if the sensitive information cannot be deleted from your submission without compromising the integrity of your story, Orlin & Cohen may decline to post your submission altogether. The following types of information are considered sensitive and will not be posted/disclosed:
HIV-related information (which is any information indicating that you have had an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information that could indication you have been potentially exposed to HIV)
Substance abuse information
Psychiatric/psychotherapy care information
Sexually transmitted disease information
Tuberculosis information
Genetic information
What is the purpose of the use or disclosure? The purpose of the use or disclosure is to share your Orlin & Cohen experience.
When will this authorization expire? This authorization will expire 15 years from the date you submit it to Orlin & Cohen. After the expiration of this authorization, Orlin & Cohen will not use or disclose your health information for the purposes described herein, unless you authorize such additional use or disclosure by submitting another authorization.
SPECIFIC UNDERSTANDINGS
By agreeing to the terms of this authorization, you authorize the use or disclosure of your protected health information, as described above. This information may be redisclosed if the recipient(s) described in this authorization is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.
You have a right to refuse to agree to the terms of this authorization. Your healthcare, the payment for your healthcare, and your healthcare benefits will not be affected if you do not agree to the terms of this authorization, but we will not be permitted to disclose your information as described on this authorization without your agreement.
You have a right to receive a copy of this authorization after you have agreed to its terms. If you would like a copy of this authorization, please send your request to: Orlin & Cohen Orthopedic Group, 1728 Sunrise Highway, Merrick, NY 11566.
If you agree to the terms of this authorization, you will have the right to revoke it at any time, except to the extent that Orlin & Cohen has already taken action based upon your authorization. To revoke this authorization, please write to Orlin & Cohen Orthopedic Group, 1728 Sunrise Highway, Merrick, NY 11566.
Unless you represent below that you are the personal representative of an adult or minor patient, Orlin & Cohen will only post information about you. If you submit information about another patient or individual that could be considered protected health information, that information will be deleted from your submission prior to your story being posted to www.orlincohen.com and/or Orlin & Cohen social media channels, or if the information cannot be deleted from your submission without compromising the integrity of your story, Orlin & Cohen may decline to post your submission altogether.
Publish Photograph Consent * Required Yes, I have read the Consent for Publishing Photographs and/or Recordings above and agree that my photos and/or Videos may be used as described above. * Required * Required
Individual Release * Required If you'd like us to tag you, please provide one or both social handles:
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