Patient Registration Form

Please correct the errors described below.

Insurance Information

If insured person is other than the patient, please complete the following:

Consent for Treatment: I consent to the care and treatment by Dr. Cabiran and/or Jane Pressler, NP. The treatment may include but is not restricted to medications, anesthesia, surgical and invasive procedures, lab, x-ray, or other studies that may be helpful in the performance of the patient's care. Assignment of Benefits and Guarantee of Account: I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office is due at the time of service. I also understand that I am financially responsible for all co-payments and any charges that are not paid by myinsurance. I authorize payment directly to Dr. Cabiran, MD and/or Jane Pressler, NP all medical or surgical benefits otherwise payable to me under the terms of my insurance. In the event an account is turned over to a collection agency, I agree to pay all costs of collection including reasonable attorney's fees and hereby waiver all rights of exemption under the constitution of the State of North Carolina/Georgia. I certify that the information I have reported with regard to my insurance coverage is correct. Exposure to Diseases: I understand that if my physician(s), or any person employed by or under the direction and control of my physician(s), is directly exposed to my body fluids in any manner which may, according to the current guidelines for the center for Disease Control, transmit the human immunodeficiency virus (HIV) or Hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I further understand that by law I am deemed to have consented to the release of these test results to those who were exposed to my body fluids. A photocopy of the authorization shall be considered as effective and valid as the original.

Highlands Dermatology Medical History

Do you have a family history of the following?

Please answer to the following questions to comply with The Medicare EHR Incentive Program.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of you manual signature on this application.

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