New Patient Form

Each year, please provide current copies of all insurance cards to the front desk.

Download the New Patient Packet.

   Male   Female

Single Widow Married Divorced

   Non-Hispanic   Hispanic
   English   Spanish   Other  

Advanced Directives
   Yes   No
   Yes   No
   Yes   No


To protect our patient’s privacy, Dr. Caballero will not disclose or release any information regarding our patients without their written authorization. Should you wish to authorize Dr. Caballero to discuss your account or medical information with someone other than yourself, please indicate this permission below by listing those individuals. I understand that I may revoke or change this Consent at any time by filling out another consent form to replace this one.

HIPAA Authorization: By checking this box I am confirming that I consent to medical disclosure to the above people.


Financial Responsibility
All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our business office.

Assignment of Benefits
I hereby assign all benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, Medicare Advantage Plans, Medicaid, private insurance, or any other health/medical plan, to issue payment check(s) directly to H & D Cardiology, PA, for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information
I hereby authorize H & D Cardiology, PA, to (1) release any information necessary to insurance carriers regarding my treatment and condition; (2) process insurance claims generated during examination or treatment; (3) allow a photocopy of my signature to be used to process insurance claims for the period lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from H & D Cardiology, PA, on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for all charges not covered by insurance if any incurred during the treatment. I further understand that fees are due and payable on the date that the services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

Authorization for assignment of benefits: By checking this box I am confirming that I understand the above information.


Welcome to our practice. At this point in your care, no specific treatment plan has been recommended, until we have had the opportunity to identify your needs. This consent form is simply to obtain your permission to perform the evaluation necessary to identify any condition that might require an appropriate treatment and/or procedure as part of your plan of care. You have the right to be informed about any condition identified and the options for recommended surgical, medical, or diagnostic procedure to be used. You may then decide whether to undergo any suggested treatment or procedure, after being informed of the potential benefits and risks involved.

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with potential risks and benefits. The consent will remain fully effective until it is revoked in writing. You have the right at any time to ask additional questions or to discontinue or decline services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice or one that has been identified. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

I am confirming that this form accurately reflects my wishes. In addition, I have kept a copy for my records. Checking this box is confirming your signature.

We are here to provide the best care available. Make an appointment today.