yca

Registration Form

Patient Name*

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

Referred By

Marital Status*

Date Of Birth*

Sex*

Age*

Driver's License Number*

State*

Social Security Number*

Home Phone:

Work Phone:

Mobile Phone:*

Address*

City*

State*

Zip Code*

Email*

Occupation

Employer

Employer Phone

Emergency Contact Name*

Emergency Contact Phone*

Please Select One*

Pharmacy Name

Pharmacy Address

Pharmacy Zip Code

Pharmacy Phone Number

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

My primary phone number :

Cell Home Work OK to leave voicemail a this number

Second Choice Number:

Third Choice Number:

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

Name

Relationship

Name

Relationship

Primary Insurance

Insured's Information*

Self Spouse Parent Other

Other

Name of the Primary Insurance*

Name of the other Primary Insurance

Policy ID Number

Group Number

Insured’s Name and Demographics

Same as above Different than above

Insured's Name*

Insured's Date Of Birth*

Insured's Employer*

Address*

City*

State*

Zip Code*

Home Phone:

Cell Phone:

Work Phone:

Secondary Insurance

Name of the Secondary Insurance*

Name of the Secondary Insurance

Secondary Insured’s Name and Demographics

Same as Primary Insured Different than Primary Insured, but same as Patient Demographics above Different than Primary Insured or Patient Demographics above

Insured's Information*

Self Spouse Parent Other

Other Insured*

Insured's Name*

Insured's Date of birth*

Insured's Employer*

Policy ID Number*

Group Number*

Address*

City*

State*

Zip Code*

Home Phone

Work Phone

Cell Phone

New Patient Medical Background

Reason for Visit

Other reason for visit:

Past Medical History

Other PMH:

Medications (Name, Dose, Frequency)

Hospitalizations/Surgeries, with Dates:

Has anyone in your family had these conditions?

Details of FH:

Allergies

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.

Select a file

I agree to the terms and conditions above.*