Medical Record Release Form

Jersey Medical Weight Loss Center/ Aparna Medical Associates

2186, Route 27, Suite 1B North Brunswick NJ 08902
Medical Records Release Authorization
I authorize the custodian of my medical records to disclose and / or release my health infomation to the following healthcare provider:
Dr. Aparna Chandrasekaran

1527 Route 27, Suite 2100

Somerset, NJ 08873

(732) 659-6650 ☎ - (732) 659-6649 📠
I understand that this authorization is voluntary and the information obtained will be used for health care purposes. By signing below, I represent and warrant that I have the authority to sign this document and authorize the use of disclosure of protected health information and that there are no claims or orders pending that would prohibit, limit or otherwise restrict my ability to authorize the disclosure of this protected health information.
Print Name *

First NameLast Name
Relationship to Patient
Date of Birth

MonthDayYear
Date
Telephone Number
Please enter a valid phone number.
Signature

Clear
Date

MonthDayYear
Date
Type of Medical Records information we are requesting

EKGLab ReportRadiology ReportConsultationsOther
Should be Empty:

Jersey Medical Weight Loss Center/ Aparna Medical Associates