Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice

Additional Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

No Show/Late Cancellation Policy

This policy is in place to keep patients, staff and providers safe. ensure that all of our patients have the opportunity to be seen in a timely manner. When a single patient arrives late, it has a snowball effect and delays care to every other patient.

A “no-show” is missing a scheduled appointment, this includes arriving 10 minutes late for your scheduled time. A “late-cancellation” is canceling an appointment without calling (the portal should not be used for urgent messages) more than 24 hours prior to your scheduled time.

If a third No Show or cancellation/reschedule with no 24 hour notice should occur the patient may be dismissed from The McCuiston Group.

As a courtesy, we make reminder calls and/or send texts/emails for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our office, and we may be able to waive the No Show fee.

You may contact The McCuiston Group 24 hours a day, 7 days a week. Should it be after regular business hours or a weekend, you may leave a message at 202.525.2426 or send a message in the portal.

a. NO Show/Late cancellation for well visit appointments – $175

b. NO Show/late cancellation for same day sick /follow up/office visit appointments – $100

c. No Show/late cancellation for a Consultation – $ 200

Please understand that insurance companies consider this charge to be entirely the patient’s responsibility and will not be covered.

COVID Questionnaire

Preventive Medical Visit Patient Information

Appointment Cancellation/No Show Policy