Privacy, Terms & Conditions
Important note regarding website content.
- Consent for Treatment
- Covid -19 Testing Consent
- HPI Disclosure notice
- Authorization to release healthcare information and payment guarantee
- Payment Policy
- Acknowledgment for non secure electronic communication
- Non-Discrimination Notice
- Equal Opportunity Employment (EOE)
If this is a medical emergency, call 911 or proceed to your nearest emergency room! Do not use our services, if you are experiencing a life-threatening emergency, loss of consciousness, difficulty breathing, chest pain, stroke symptoms, poisoning or overdose, head injury, uncontrolled bleeding, or other medical emergencies.
CONSENT FOR TREATMENT
- I voluntarily consent to Vitality Urgent Care (VUG) and consent 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 guarantee can be made or has been 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 VUG. I acknowledge that treatment at VUG intended to address specific episodic illnesses or injury and is not intended to substitute for comprehensive care in lieu of 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 VUG if fail to comply with the above conditions.
- Patients at VUC will be treated regardless of race, color, age, national origin, disability or religion. Notwithstanding the above criteria, VUC reserves the right to refuse care to any individual who may have an unpaid balance, exhibits rude or disruptive behavior or any other reason at the discretion of the physician on duty.
COVID-19 TESTING CONSENT
- I voluntarily consent and authorize Vitality Urgent & Primary Care to conduct the collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false-negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider or contact Vitality Urgent & Primary Care for consultation.
- I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
- I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
- I understand the testing unit is not acting as my primary medical provider, this testing does not replace treatment by my primary medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my primary medical provider if I have questions or concerns, or if my condition worsens.
- I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.
Pre-Travel and Corporate Covid-19 Testing Disclaimer
- I understand that Vitality Urgent Care will not be submitting a bill to my insurance and that my private payment services will not factor into my insurance plan’s maximums.
- I understand that I am not using insurance for these services for testing services wit Vitality Urgent Care. I freely choose to self-pay for COVID-19 services and understand the associated clinic and partner laboratory testing policies.
- If I have insurance coverage and am choosing not to use it, I am aware that there may be other providers who are may be in network with my insurance company, and that if I were to see those providers, some/all of my bill could be covered by insurance benefits.
Clinical Laboratory Services Coordination Disclaimer:
- Vitality Urgent Care partnered with multiple Clinical Laboratory partners to facilitate COVID 19 RT-PCR testing Services and Results Reporting. Vitality Urgent Care Provides referrals and event coordination but does not have direct ownership in Clinical Laboratory partners.
Our commitment to your privacy:
- Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We may use and disclose your PHI in the following ways:
- Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other healthcare providers for purposes related to your treatment.
- Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other healthcare providers and entities to assist in their billing and collection efforts.
- Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other healthcare providers and entities to assist in their health care operations.
- The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
Authorization to release healthcare information and payment guarantee
I authorize the release of my medical records, treatment and advice, and specific health information to:
- TREATING PHYSICIANS on staff at Vitality Urgent Care and their staff, agents of another healthcare facility if direct transfer to another facility is required, and to my primary care physician or any referred consultants for follow up care.
- AN EMPLOYER who requests services. This may include your personal medical history, physical, laboratory and diagnostic tests, and drug screenings (including the presence of drugs, alcohol or marijuana).
- INSURANCE COMPANY or other third-party payer and their agents as well as any review organization or government agency for the purpose of determining eligibility and available benefits, obtaining payment for services provided, and insuring government compliance.
I, the undersigned, authorize the Vitality Urgent Care to submit claims to my insurance company. I authorize to use and disclosure of my personal information for the purposes of diagnosing or providing treatment to me, obtaining payments for my care, or for the purposes of conducting the health care operations of the practice. I also authorize Vitality Urgent Care to release any information required in the process of application for financial coverage for the services rendered. This authorization provides that the practice may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agents. If it is the case that my insurance company utilizes a managed care company, my therapist may need to discuss my treatment with a case manager. I understand that my confidentiality will be compromised in such a case. I realize that his/her doing so is a necessity in his effort to secure ongoing care.
- We may ask to collect secure credit card information prior to the scheduled visit. We’ll only charge your card when you get care from a Vitality Urgent Care provider, and we’ll always let you know beforehand.
- 1. After your visit, Vitality bills your insurance carrier with appropriate cost codes for service. These codes vary depending on whether you’re a new patient to us or not, and whether a prescription medication was given. (It’s actually a little more complicated than that, but that’s the gist.).
- 2. Based on your individual plan, your insurance carrier will pay all or some of that claim directly to us. Note – the claims process typically takes about 2-6 weeks, and coverage/reimbursement varies depending on how your employer has structured their plans.
- 3. If, for some reason, your insurer elects to not cover the full amount, the remaining balance is settled to your account on file. Your insurance carrier will apply this amount to your “in-network deductible”. We’ll always send a detailed statement at least 5 days before settling unreimbursed medical service charges to your account.
- 4. Vitality Urgent Care will not be submitting a bill to insurance for pre-travel covid testing and that payment service may not factor into my insurance plan’s maximums.
- Fair & Transparent Pricing
Our commitment is to fair and transparent pricing. While we can never predict how insurers will treat individual claims, we encourage you to discuss any questions with us. Additionally, we will never charge any patient – insured or not – more than our flat-rate pricing.
- 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.
TRAVEL/CONVENIENCE FEES ACKNOWLEDGEMENT (Only for House-Calls)
Patient acknowledges that mutually agreed TRAVEL FEES payable by Patient to Vitality Urgent Care has no relation or insurance claim and does not count towards the insurance copay, coinsurance, or deductible. Patient will be financially responsible for payment for all healthcare and medical care services received by Patient from the Designated provider and his or her staff. This Services Agreement is not intended to serve as or replace any health plan and should in no manner be considered a form of prepaid healthcare or insurance Services Agreement.
- I understand that Vitality Urgent Care will not be submitting a Travel fee to insurance and that my private payment services will not factor into my insurance plan’s maximums.
- I freely choose to self-pay for customary Travel fees understand the associated clinic policies.
- I am aware that there may be other providers who may have different fee structure and may if I were to see those providers, some/all my bill could be covered by insurance benefits.
CANCELATION AND NO SHOW POLICY
- Vitality has made a commitment to you, our patients, to see you as close to your scheduled appointment time as possible. When a patient does not show up for a visit or cancels/reschedules on the day of the appointment, it creates a hole in the schedule that can’t be filled. This is not fair to the patients and practice,
- Please call us at (224) 601-5001 by at least 24 hours in advance of your scheduled appointment to notify us of any changes /cancellations. You may cancel an appointment online within 24 hours prior to the appointment. If prior notification is not given, you will be charged 50% of the prepaid visit price for the missed appointment.
ACKNOWLEDGEMENT FOR NON-SECURE ELECTRONIC COMMUNICATION
- Standard email communication (Gmail, Yahoo, etc) is an easy and convenient way to communicate with Healthcare Providers. Skype and Facetime provide additional means of communication that bridge the gap between an in-person visit and phone or email. Texting is a quick way to communicate short and more time-sensitive messages. All these methods of communication are non-encrypted and therefore not considered fully secure, and do not meet the security requirements set forth by the Health Insurance Portability and Accountability Act (HIPPA).
- I, the undersigned, have read and understood the above, and consent to non-secure electronic communication. I release Vitality Urgent and Primary Care from any and all liability that may arise from the use of non-secure communication. If at any time in the future I wish to revoke this consent, I will so inform Vitality Urgent and Primary Care by fax or by secure message via Patient Fusion. This revocation will not be retroactive, and will only affect communication going forward from the date of such revocation
All content on the website contains general educational information about medical conditions and treatments. The Content on this website should not be considered medical advice and is not intended as medical advice. You agree not to hold us liable for any damages arising from or relating to your reliance on any of the medical information provided on this website. Additionally, you agree not to repeat the medical information that you read on this website to a third party, as that third party may not have read this disclaimer and understood the caveats involved in receiving the information.
If you have questions about this Notice, please contact Vitality Urgent and Primary Care administration for additional details at 224.601.5001 or via email: firstname.lastname@example.org
Non-Discrimination Notice for Urgent Care
Non-Discrimination Notice for Vitality Urgent Care
Vitality Urgent Care complies with all applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Vitality Urgent Care does not exclude individuals or treat them differently on the basis of race, color, national origin, age, disability, or sex.
At Vitality Urgent Care, we offer free aids and services to people with disabilities to ensure effective communication with us. These aids and services include qualified sign language interpreters or written communication, written information in alternative formats such as large print, audio, accessible electronic formats, or other formats as needed.
We also provide free language services to individuals whose primary language is not English. These language services include qualified interpreters and written information in other languages.
If you require these services, please contact Vitality Urgent Care at 224.601.5001.
If you believe that Vitality Urgent Care has failed to provide these services or has discriminated against you on the basis of race, color, national origin, age, disability, or sex, you may file a grievance with our Grievance Coordinator. The Grievance Coordinator’s name and contact information is as follows:
Rod Levin 137 W Rand Rd, Arlington Heights, IL., 60004, 224.601.5001 E-Mail: email@example.com
You may file a grievance in person or by mail, fax, or email. If you need assistance in filing a grievance, our Grievance Coordinator is available to assist you.
You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, which is available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Equal Opportunity Employment (EOE)
Vitality Urgent Care Arlington Heights center us an equal opportunity employer and is committed to providing a diverse and inclusive workplace. We do not discriminate against any employee or applicant for employment on the basis of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity or expression, marital status, genetic information, or any other protected status under applicable law.
We are dedicated to promoting a culture of respect, fairness, and equal opportunity for all employees, as well as creating an environment where everyone can thrive and contribute to the success of our organization. We value diversity and are committed to creating a workplace that is welcoming to all.
Vitality Urgent Care encourages applications from all qualified individuals, including women, minorities, individuals with disabilities, veterans, and LGBTQ+ individuals. We believe that a diverse and inclusive workforce is essential to our success and our ability to provide the best possible care to our patients.
If you require any accommodations to apply for a job or participate in the interview process, please let us know. We are committed to making our hiring process accessible to all candidates.
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- Can I get a DOT drug test at Vitality Urgent Care?
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