Bachir Younes M.D. , MPH

Younes Medical Corporation

Registration Form

The questions below are Government Required for Electronic Medical Care Reporting

Insurance Information

Consent to Disclose Health Information for Payment, Treatment, and Health Care Options

I have been provided with a summary of Younes Medical Corporation's Notice of Privacy Practices, which states how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the notice and request the following restrictions concerning the use or my personal medical information:

I give permission for Younes Medical Corporation to call my home and disclose medical information on my answering machine:

Assigment and Release

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.