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Consent for Treatment

  • I voluntarily consent to medical care at Vitality Urgent Care and to treatment by the nurse practitioner on duty and whomever they may designate as their assistant, associate, physician, and patient care staff to provide my care. Such care may include, but is not limited to, diagnostic testing and the administration of medications considered advisable in my diagnosis, treatment, and course of care. I acknowledge that no guarantees can be made as to the results of treatments or examinations and I understand that all medical treatments contain inherent risks.
  • I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of my examination or treatment at Vitality Urgent Care. I acknowledge that treatment at Vitality Urgent Care is intended to address specific episodic illnesses or injuries and is not intended to substitute for comprehensive care by a primary care Physician or other specialized physicians. To provide the best chance for successful treatment, I accept responsibility to follow the advice of my treating provider, including compliance with medications, discharge instructions, and reevaluation with follow-up or referral to specialty care. I agree to seek care in an Emergency Department of a hospital if my condition substantially changes. I further agree to hold harmless the medical providers and staff of Vitality Urgent Care if I fail to comply with the above conditions.

    Payment Policy

    • I agree that I will be responsible for payment of the complete charges for all services not covered by my insurance carrier/third party payer. I agree to pay the account in full upon receipt of my billing statement.
    • If I do not pay the entire new balance within 30 days of the monthly billing date, I realize that may not be able to provide additional services. In the case of default on payment of this account, I agree to pay collection costs of 30% and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. It is our policy that any insurance co-pays and deductibles or any balance of a bill owed by those without insurance is due at the time of service.

    Credit Card on File

    Vitality Urgent Care is dedicated to improving your experience with us. Our ‘Credit Card on File’ system is designed to streamline billing, making it more efficient and transparent. This system ensures:

    • No waiting for bills in the mail.
    • Receipt of clear, itemized statements.
    • More focus on your healthcare, less on paperwork.
      By adopting this approach, we aim to enhance the convenience of your healthcare journey with us.

    Here’s how it works:

    • Initial Setup: Prior to your visit, we collect and securely store your credit card information for future billing.
    • Safety Measures: The card data is stored securely in our encrypted electronic health record system, without access to our staff or presence on our premises.
    • Insurance Billing: If we accept your insurance, we’ll file your claim as usual.
    • Explanation of Benefits (EOB): After your claim is processed, you’ll receive an EOB from your insurer, specifying what amount you owe.
    • Card Charge: 7-10 business days after receiving the EOB, your stored credit card will be charged the remaining balance. If you owe nothing, your card won’t be charged.
    • Electronic Statement: A detailed statement will be sent to your provided address, summarizing any charges made.

    By signing this document, I consent to the ‘Credit Card on File’ policy and authorize Vitality Urgent Care to store and charge my credit card for the services rendered as per the policy outlined above.


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