yca2

HIPAA Privacy Authorization Form

Patient Name *

Date of Birth *

Patient's phone number

Name of Healthcare Provider or Facility

Address

Phone number

Fax number

Younis Cardiology Associates, PLLC
6560 Fannin St. Suite 1750
Houston, TX 77030
Phone 713-790-0400. Fax 713-799-2121

This request and authorization applies to:

All healthcare information Only healthcare information relating to the following treatment, condition or dates:

Date Signed *