By clicking "SUBMIT" on this form, I hereby authorize Younes
Medical Corporation to release any and all medical records to my Insurance
company in order to process this or any future medical claims with this
office. I understand that I am financially responsible for payments due
at the time of services rendered by Younes Medical Corporation. This includes
payment in full if Younes Medical Corporation is not a provider with my
insurance company, and any deductible amounts or co-payments which apply
at the time or services.