Orthopaedic Specialists of Conneticut

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X-Ray/Medical Records Request Form

Authorization for use and disclosure of X-rays and Medical Records.

Completion of this document authorizes the disclosure and/or use of identifiable health information, as set forth below, consistent with Connecticut and federal law concerning the privacy of such information.

Patient Information

* Required Fields

I hereby authorize the use and disclosure of the above health information and release X-rays for myself or for a minor for which I am the guardian.

Organization Releasing Information

All Requests Will Be Processed Within 1-2 Business Days

CD's are Not Protected and are The Patients Responsibility to be Safeguarded.

** There is a $7.00 fee per sheet of copied Film or per CD. **

Please indicate specific study types and the dates

X-ray Request

Body Part Approx. Dates (month/day/year)
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All original X-ray films are the property of OSC and we are required by the State of Connecticut to keep them on file for 3 years. Please return all original fims within 30 days of pickup.

There will be a $20.00 cash refundable deposit required to take out your original films and will be returned when the films are returned

Please acknowledge you have read this.

Medical Records Request

Body Part Approx. Dates(month/day/year)
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OSC will provide the first 10 (ten) pages of your medical record for free, an additional 65 cents per page will be charged for pages over ten to be paid at the time of pick up. If your request incurs a fee please indicate that you would like to be called prior to us processing this request.

Please provide your preferred phone number so we can call you prior to processing your request, as well as to inform you of the associated fees.

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