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.