Financial Policy

Thank you for choosing Vitality Urgent Care for your medical needs. Vitality Urgent Care is dedicated to providing exceptional healthcare services. Our Patient Financial Responsibility Form is designed to ensure a mutual understanding of our payment requirements and your financial responsibilities.

Insurance Policy

• We will file your insurance claims directly with your insurer, provided you submit accurate and complete insurance details at check-in for eligibility verification.
• Responsibility for Non-Covered Services: In instances where your insurance does not cover certain services or supplies, you will be responsible for these costs at the time of service or upon claim settlement.
• Follow-Up on Delayed Insurance Payments: If we do not receive payment from your insurance within their specified timeframe, the outstanding balance will become your responsibility.
• Deductibles, Co-Pays and Coinsurance: Estimated amounts are collected upfront based on your verified benefits.
• Non-Network Insurance: If we are not in network with your plan, visits are billed at our posted self-pay rates. A 20% discount applies if paid in full at the time of service.
• Advance Beneficiary Notice (ABN): Medicare patients receive an Advance Beneficiary Notice of Noncoverage before any service Medicare may not cover. A signature is required.

Self-Pay Policy

• As a self-pay patient, you are required to settle the full balance of your account at the time of discharge. Self-pay pricing is posted at vitalityurgentcare.com/price. Self-pay discounts do not apply to motor vehicle accident or workers’ compensation cases.

Workers’ Compensation Policy

• Direct Billing to Employers or Carriers: For workers’ compensation cases, we bill your employer or their compensation carrier directly. This process is to simplify your experience and ensure compliance with workers’ compensation laws. I understand that medical information related to my work injury or illness will be provided to my employer and their workers’ compensation carrier as required by workers’ compensation law.
• Acceptance of Contracted Rates: We adhere to state-mandated fee schedules and accept payments accordingly from workers’ compensation carriers.
• Alternative Billing in Case of Denial: If workers’ compensation denies payment, we will then bill your private insurance. Should your private insurance also deny the claim, the responsibility for the payment falls to you.
• Providing Employer and Insurance Information: To facilitate billing, it’s crucial that you provide us with accurate information about your employer or their insurance company.

Payment Policy

• Accepted Methods: Credit cards, debit cards, HSA/FSA/HRA cards, cash, and personal checks.
• Returned Checks: If a check is returned unpaid, I agree to reimburse Vitality Urgent Care’s costs and expenses of collection as permitted by Illinois law (810 ILCS 5/3-806), and Vitality Urgent Care may require certified funds or another payment method for future payments.
• Declined Card on File: If the card on file is declined, Vitality Urgent Care will contact me for another payment method. Unpaid balances are handled under this Payment Policy.
• Full Payment for Non-Covered Services: You are expected to pay in full for any services not covered by your insurance. This includes receiving a comprehensive billing statement for such services.
• Outstanding Balances: Prior balances may need to be addressed before service. Payment arrangements are available — ask our team.
• Consequences of Non-Payment: Failure to pay the new balance within 30 days of the billing date may lead to a restriction on further non-urgent services.
• Financial Hardship and Assistance: If you are unable to pay at the time of service, speak with our front desk. We will explore self-pay rates, payment plans, or referrals to community resources. Your financial status will never delay or limit your care in an urgent or emergent situation.
• Collection and Legal Fees: In the event of non-payment, you agree to bear reasonable collection costs and reasonable attorney fees incurred in the process of collecting outstanding balances, to the extent permitted by law.

Credit Card on File

• Keeping a credit card on file allows Vitality Urgent Care to simplify billing and reduce the need for paper statements or follow-up invoices.
• Who is required to keep a card on file: All patients with commercial insurance or Medicare. A card is not required if you are a self-pay patient paying in full at the time of service, if you are presenting with a medical emergency, or if you have verified active Medicaid coverage.
• Secure Card Storage: Your credit card is securely stored using an encrypted, PCI-compliant payment system. Vitality Urgent Care does not store full credit card numbers within the clinic system.
• Insurance Processing and Billing: My visit is submitted to my insurance first. I am responsible for all amounts my insurance does not cover or determines to be my responsibility — such as my deductible, co-insurance, or co-pay — as shown on my Explanation of Benefits (EOB). The first charge is typically processed approximately 7 to 10 business days after the EOB.
• Monthly Charge Limit: My card is charged no more than once per calendar month, and no single charge will exceed $250. If my balance is larger, the remainder is charged in the following month or months — one charge per month — until the balance is paid. I will receive an email before each charge showing the amount and my remaining balance. No interest or fees are added, and I may pay my balance in full or arrange a different schedule at any time.
• Removing Your Card: You may request removal of your card at any time by contacting our billing office. Removal may require prepayment in full at future visits.
• A plain-language guide to this policy, with examples and frequently asked questions, is available at the front desk and on our website.

Credit Card on File — Authorization

• I authorize Vitality Urgent Care to securely store my credit card and to charge it — no more than once per calendar month, and never more than the monthly limit stated above — for amounts my insurance determines to be my responsibility as shown on my Explanation of Benefits. I understand I will not be charged if no balance is owed, that an email notification precedes each charge, and that I may pay in full at any time, arrange a different schedule, or contact the billing department to dispute any charge.

Financial Responsibility Authorization

• By my signature below, I acknowledge that I have read and agree to this Patient Financial Responsibility Form, and I understand that I am financially responsible for any charges not covered by my insurance.

Patient Financial Responsibility Form · Version 2.0 · Effective 07.17.2026 · Vitality Urgent Care · 56 W Dundee Rd, Buffalo Grove, IL 60089 · 224.601.5001 · 480 S Rand Rd, Lake Zurich, IL 60047 · 847.350.1291