Allergy, Ears, Nose and Throat Associates of Texas
Tariq Yunus, MD

logo

New Patient Registration Form

Patient Information

Insurance Information

PAYMENT POLICY

I irrevocably authorize my insurance benefits to be payable directly to Dr. Yunus and/or the attending physician on my behalf. I understand that I am responsible for all co-insurance and non-covered charges. I understand that payment is due in full at time of service and if not I am responsible to make the appropriate financial arrangements. I consent to the release of information from my medical record as necessary for the collection of services being rendered by this establishment. I also understand that I am responsible for the payment of reasonable attorney fees and collection expenses if required for the collection of the account.

Patient History

PAST MEDICAL HISTORY (Check (X) conditions you have or have had in the past)
SOCIAL HISTORY (Check (!) and describe all that apply.)
 
FAMILY HISTORY (Please explain Whom in your family has the following.)
PAST SURGERIES AND HOSPITALIZATIONS (with year of occurrence).
CURRENT MEDICATIONS
ALLERGIES TO MEDICATIONS
REASON FOR VISIT
REVIEW OF SYSTEMS (Check (!) symptoms you currently have or recently had.)
EYES

EAR, NOSE, THROAT

GENERAL

CARDIOVASCULAR

RESPIRATORY

GENITO-URINARY

GASTROINTESTINAL

MUSCLE/JOINT/BONE
Pain, weakness, numbness in:

NEUROLOGICAL

ENDOCRINE

HEMATOLOGIC/LYMPHATIC

SKIN

Consent for Release

The use or disclosure of this information will be made by the medical office staff. The practice is hereby authorized to make the disclosure of this information to these classes of persons. I understand that I have the right to recoke this authorization, in writing, at any time by sending such written notification to above noted person. I understand that a revocation is not effective to the extent that the practice has relied on this authorization in it's actions. Also, a revocation is not effective if this authorization was obtained as a condition of abstaining insurance coverage, as other law provides the insurer with the right to request a claim under the policy or the policy itself. I understand that information used or disclosed pursuant to this authorization may be subject to disclosure by the recipient and may no longer be protected by the federal HIPPA privacy regulations. The practice will not condition my treatment, payment, enrolment in a health plan or eligibility for benefits on whether I provide authorization of the requested use or disclosure of information.

This authorization is in force and effective for one year from date below.