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.

Late/Missed Appointment Policy

At The McCuiston Group we believe that convenience and efficiency are an important part of the clinical care experience.  We strive to provide care that meets this criteria. In order to limit infectious exposure between families, keep things orderly and running as smoothly as possible, we must honor appointment times.

We do understand that sometimes there are circumstances that we cannot control and this may affect a patient’s ability to arrive on time for their appointments.  If you are late for your appointment, we will do everything we can to see you, however, if you are 5 minutes late for a visit and we are unable to work you in or you are unable to wait, you will have to pay the associated fee. A late cancellation is any cancellation less than 24 hours before the scheduled appointment time.

a.  Missed Appointment/Late Cancellation for Well visit -$100

b.  Missed Appointment/Late Cancellation for Sick Visit  – $50

c.   Missed Appointment/Late Cancellation for a Consultation   – $150

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.

COVID Questionnaire

Preventive Medical Visit Patient Information

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.

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