Request Your X-Rays

Patient Identification

First Name*
Please enter your first name

Last Name*
Please enter your last name

Date of Birth*
Please enter your date of birth

Please enter your street address

Please enter your city

Please select a state

Please enter your zip code

Please enter a valid phone number

Please enter a valid email address

To whom should these x-rays be sent?*
Please enter a person or company name

Please enter your street address

Please enter your city

Please select a state

Please enter your zip code

Films Requested*
Please describe what medical records are to be disclosed

Total number of copies*
Please select the total number of films to copy

Total number of scoliosis films
Please select the total number of scoliosis films

Payment Method*
Please select a payment method

Payment Instructions:

  • If you are paying by Credit Card, you will be notified by the X-Ray department after your request has been reviewed.
  • If paying by check, please make check payable to "Reconstructive Orthopaedic Associates" and mail to:
    Rothman Institute
    925 Chestnut St., 5th Floor
    Philadelphia, PA 19107
    Attention: Billing Department/Karen

Please Note:

  • CD's will be mailed to the requested address for an additional CHARGE of $5.00 + $10.00 Shipping Fee ONLY AFTER WE RECEIVE:
    • This form completed in its entirety.
    • Full payment for all copies plus the $10 mailing fee.
Purpose or reason for request*
Purpose For Request Required

I knowingly and voluntarily authorize the Rothman Institute 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 below.)

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 the Rothman Institute, 925 Chestnut Street, 5 th Floor, Philadelphia, PA 19107, Attention: Medical Records Requests.

I understand that there is a fee associated with requests for records. This fee will be invoiced to the requestor and is required to be paid prior to the request being processed. Please allow 7-10 business days to process your requests after payment has been received.

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 Rothman Institute, its employees and agents to process this request.

This authorization will expire on*
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