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.

Become a Patient

Whether you are new to the area or currently are not established with a primary care provider, look no further! Mount Vernon Internal Medicine has highly qualified Physicians and Nurse Practitioners who are available to help.

Please review the provider photos and biographies on our Meet the Team page.

If you have questions please contact our call center representatives for guidance on which provider is the best fit for you at 703.780.2800.


1. Your current Insurance Card and a valid Photo ID. We follow very strict privacy guidelines. In order to protect our patient’s identity and prevent fraud, we require both of these at the time of your appointment.

2. Completed Care Visit Form which will include:
– A list of providers/specialists from whom you receive care.
– A list of your medications and their dosages; both over the counter and prescribed.
– A list of your previous surgeries or conditions that you have received treatment for.

3. Your vaccination record.

Please arrive 30 minutes prior to your scheduled appointment time to allow us time to verify your information and fill out any necessary paperwork. To provide top notch care, we like to know who our patients are and to be able to fulfill this, we will ask you about your family history and other vital background information during your first appointment.

** If you have a HMO insurance and another provider’s name is listed as your PCP on your card please call your insurance company to have this changed before coming in for your appointment. Unfortunately, insurance companies do not allow us to make this change on your behalf.

** If you are receiving care due to an injury covered by a Workman’s Compensation Insurance, please note, you must contact your case worker before your appointment and receive authorization to see us. We will need your claim number, authorization number, case worker’s contact information and the name, address and phone number of the Insurance Carrier.

Our providers will be delighted to fill out any medical forms for patients. However, in order to do this, ample time must be given. It will take approximately one to two business days for the forms to be completed. You will need to let us know how you would like to receive your medical forms. Please see the Authorization For Release Of Medical Information form below for more information.