CONSENT FOR TREATMENT

Consent for Treatment

I voluntarily consent to medical care at Vitality Urgent Care and to treatment by the nurse practitioner on duty and any assistant, associate, physician, clinical team member, or patient care staff member designated to participate in my care.

This care may include evaluation, examination, diagnostic testing, laboratory testing, imaging services, procedures, medication administration, treatment, discharge instructions, referrals, and other services considered medically advisable based on my condition and the clinical judgment of my treating provider.

I understand that the practice of medicine is not an exact science. No guarantee has been made regarding the outcome of any examination, test, medication, treatment, procedure, referral, or course of care. I understand that all medical treatment carries inherent risks, including the possibility that symptoms may worsen, fail to improve, or require additional evaluation elsewhere.

I understand that Vitality Urgent Care provides episodic urgent care and immediate care services for acute illness, injury, testing, occupational health, and related medical needs. I understand that urgent care does not replace comprehensive longitudinal care by a primary care physician or care by a specialist when such care is medically indicated.

I agree to follow the advice of my treating provider, including medication instructions, discharge instructions, follow up instructions, specialist referrals, and reevaluation recommendations. I agree to seek emergency care in a hospital emergency department or call 911 if my condition becomes severe, changes, or worsens.

Authorization to Release Healthcare Information

I authorize Vitality Urgent Care to use and disclose my protected health information for treatment, payment, and healthcare operations consistent with the Vitality Urgent Care Notice of Privacy Practices.

I authorize Vitality Urgent Care to submit insurance claims on my behalf and to release clinical, demographic, billing, and other information necessary to my insurance carrier, payer, plan administrator, third party administrator, or their agents for claims processing, payment review, benefits determination, utilization review, coordination of benefits, medical necessity review, appeals, audits, or related administrative purposes.

I authorize Vitality Urgent Care to release information reasonably necessary for financial coverage applications, billing support, referral coordination, pharmacy communication, laboratory processing, imaging interpretation, continuity of care, and other services related to the healthcare provided to me.

Consent to Non Secure Electronic Communication

I understand that Vitality Urgent Care may communicate with me through convenient electronic methods, including email, text message, video communication, patient portal messaging, or other electronic tools when appropriate for scheduling, clinical follow up, administrative communication, billing, or care coordination.

I understand that standard email, text messaging, FaceTime, and similar communication channels may not be fully secure and may not meet all HIPAA security standards. More secure communication options may be available, including phone, fax, and patient portal communication.

I accept the risks associated with using less secure communication methods and understand that I may request that Vitality Urgent Care stop using these methods by calling 224 601 5001 or emailing info@vitalityurgentcare.com. Any revocation will apply prospectively from the date it is received and processed.

Consent to Receive SMS Communication Optional

By providing my mobile phone number and checking the SMS consent box, I consent to receive SMS text messages from Vitality Urgent Care regarding my healthcare and account. These messages may include appointment reminders, scheduling updates, visit follow up instructions, laboratory notifications, prescription notifications, billing notifications, and other care related or account related notices.

Message frequency may vary depending on my healthcare needs and interactions with the clinic. Message and data rates may apply depending on my mobile carrier plan. SMS messaging is voluntary and is not required to receive medical care. I may opt out at any time by replying STOP to any text message. For assistance, I may reply HELP.

Privacy Policy: https://www.vitalityurgentcare.com/privacy-policy/
Terms and Conditions: https://www.vitalityurgentcare.com/terms-conditions/

Acknowledgment of Receipt of HIPAA Notice of Privacy Practices

I acknowledge that I have been provided with the opportunity to review the Vitality Urgent Care HIPAA Notice of Privacy Practices. This notice explains how my protected health information may be used and disclosed and how I may access additional information about my privacy rights.

I understand that I may request a copy of the Notice of Privacy Practices at any time.