OCEAN CARDIOVASCULAR, LLC
MURAT KARATEPE, M.D., FACC
ASU RUSTEMLI, M.D., FACC
25 Mule Rd., Suite B2, Toms River, NJ 08755
2101 Lake Rd., Whiting, NJ 08759
Phone(732) 505-9005 Fax (732) 505-9919
Date: ___________________
Patient: ______________________________________________________
I, ____________________________________, hereby authorize Ocean
Cardiovascular, LLC and its physicians and or staff to discuss my medical
condition with:
Name: ______________________________________________________
Phone: __________________________
Relationship: ______________
I, ____________________________________, authorize Ocean
Cardiovascular, its physicians and or staff to leave messages for me at home
regarding test results, scheduling of appointments and other issues related to
this medical office.
I, ____________________________________, DO NOT authorize Ocean
Cardiovascular, its physicians and or staff to discuss my medical condition
with anyone other than myself.
Signature of patient: ____________________________
Witness: ______________________________________
Date: ________