Registration Form

Please enter your First, Middle, and Last name here.

I authorize contact from this office to confirm appointments, treatment, and billing information in the following sequence:

Please List any other parties who can have access to your health information:

Primary Insurance

Secondary Insurance


New Patient Medical Background



Assignment of Benefits and Financial Agreement

I hereby give authorization for payment of insurance benefits to be made directly to Younis Cardiology Assoiciates (YCA).I understand that i am finacially responsiable for all charges whether or not they are covered by insurance.In the event of default. I agree to pay to all costs of collection and reasonable attorney fees.I authorize YCA to relese any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.A photocopy of this agreement shall be as valid as the agreement.